Name of company, DBA or sole proprietorship.

Please enter business EIN, Tax ID or sole proprietor social security number.

The number of owners, officers or employees that may enroll in benefits within the first 30 days.

If you are new to Planstin please select, "New Enrollment". If you are making a plan change, please select, "Plan Change".

Enter your existing group number.

List the number of all officers, owners, employee and contractors that are to be paid using the payroll service.

See Payroll/HR Options.

By choosing to self-fund or level-fund your company medical plan you’re creating an employer sponsored plan under the Employment Retirement Income Security Act (“ERISA”) and the Patient Protection and Affordable Care Act (“PPACA”). Reoccurring monthly payments by credit card or bank account draft are required. Planstin may cancel or charge additional administrative fees if not on a reoccurring payment plan.

Administration Services Only (ASO) Minimum Essential Coverage (MEC) plan provides the benefits required to satisfy the individual mandate of the ACA laws. Large groups should also consider offering a plan that meets minimum value (MVP). By selecting the ASO MEC you understand that the claims costs of the plan are not included in the monthly charges. If a claim is to arise you agree to have the cost of the claim deducted from your billing account indicated.

The Preventive plan series are level-funded plans. By electing to level-fund your claims with us you are locking in your rate for the plan year and forfeit any unearned claim funds.

What name is the account in? (Ex: "ABC Sample Business" or name of sole proprietor)

By typing your name below you are giving payment authorization for initial and monthly payment of enrolled plans. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Planstin Inc in writing of any changes in my account information within 15 days. This payment authorization is required for plan administration. In the case of an ACH or Credit Card Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Planstin Inc or its assigned third party may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 charge for each attempt returned. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing so long as the transactions correspond to the terms indicated in this authorization form.

Enrollment of employees are to be completed after the company setup. Once completed you will receive additional instructions for each employee to enroll in benefits.