Sales Intake Form
Upload the Data Gathering Form and Specify all required fields
Please identify the new business type
*
New Group to OCA
Existing Group Adding Line of service
QualCare Conversion
QualCare Conversion Type
*
Group is moving to QualCare
Group is moving away from QualCare
Who is the new insurance carrier?
*
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Sales Intake Form
Upload the Data Gathering Form and Specify all required fields
OCA Sales Rep
*
Tim Kameraj
Brian McCauley
John Crotty
Jason Davey
Ross Honig
Steve Honig
Sales Retention Rep.
*
Involved with new business
Not involved in new business
Sales Rep. Email
*
example@example.com
Company Name
*
Inception Date
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-
Month
-
Day
Year
Date Picker Icon
Calendar vs. Plan Year
*
Calendar Year
Plan Year
Services Selected
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HRA
FSA
COBRA/State Continuation
Retiree Billing
Commuter
HSA (PNC)
Section 125 Premium Only Plan
ERISA Wrap Document
5500 Filing
BrokerExpress
Other
Association/Carrier Discounts?
Current QualCare (MEWA) Subscriber
Non-for-Profit Group
Select the fees that apply
*
QualCare $250 fee (HRA/FSA)
(50+ Groups) $8 HRA Bundle PPPM + $500 Annual
(1-49 Groups) $8 HRA Bundle PPPM + $250 Annual
$8.50 HRA Bundle + Commuter PPPM + $500 Annual
(50+ Groups) $6 FSA Bundle PPPM + $500 Annual Fee
(1-49 Groups) $6 FSA Bundle PPPM + $250 Annual Fee
$3.75 Commuter PPPM +$200 Annual Fee
$250- Standalone Section 125 Annual Fee
$0.70 COBRA/State Continuation PPPM
$4.95 Retiree Billing PPPM
Other
ERISA Compliance Services
*
$650 Wrap Document ($300 yr. 2)
$350 Per 5500 Filing
$450 Late 5500 Filing
$625 Wrap Doc. KTB Pricing ($300 yr. 2)
Other
How many TIMELY Form 5500s will be filed?
*
How many LATE Form 5500s will be filed?
*
HSA Pricing Selection
*
HSA Standard: $2.95 Per Account Per Month
(Optional) Onsite Educational Meeting: $250 Per year
Other
Reimbursement Options
*
N/A
Direct Deposit
Pay Provider Option (HRA only)
Paper Check Reimbursement
Debit Card
ClaimsExpress Reimbursement
ClaimsExpress Substantiation
Other
Additional Fees
*
N/A
Monthly Minimum Applies
Monthly Minimum Waived
$0.40 ClaimsExpress PPPM
$1 Per Paper Check Fee
Other
BrokerExpress Pricing Options
$50 Per Month ( Includes 125 Lives) $0.40 after
$100 Per Month (Includes 250 Lives) $0.35 after
$150 Per Month ( Includes 500 Lives) $0.30 after
Is the broker paying for any services? If yes, please provide additional information in the fee comments section and provide Broker Mailing address below.
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Fee Comments
Requesting HRA No Pay Card
*
Yes
No
# of Cards
Confirm Carrier Name
HRA Plan Design:
Delivery Method
Pick up at OCA
Mailed to Employer
Mailed to Broker
No Pay Card Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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GA/Broker Information
General Agency Name
Unknown
Savoy Associates
BenefitMall
EmersonReid
Walsh Benefits
Martin Insurance Group
PGP
FILCO
FNA
Kistler Tiffany
Rampart
Slattery/Bollinger
Broker Direct
GA/Broker Commission Schedule
SA 13% (9 GA/4 Broker)
SA 9% (GA Only)
Standard 9% (5 GA/4 Broker)
GA Standard 5% (GA Only)
Broker Standard 3% (Broker Only)
Not applicable (i.e. KT/QC/etc.)
Broker Contact Name:
*
Broker Agency/Firm Name (if known)
Additional Broker Commission Requested?
*
Yes
No
Broker Commission Requested
*
Additional Plan
Who should the implementation team contact for implementation set up questions?
*
Broker Only
Employer
Both
ERISA Implementation Specialist Email (IRIS @ BC2)
*
Iris@bc2co.com
ERISA Implementation Email (Tracey @ BC2)
*
tbennett@bc2co.com
COBRA Implementation Specialist Email
*
This will now be Courtney at cbrower@oca125.com
Upload New Group Paperwork
*
(i.e. DG, Enrollment, etc.)
Cancel
of
Additional Plan Comments
Submit
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