Employers

Since the Affordable Care Act passed, the group health landscape has seen crazy changes like: BIG increases to deductibles & out of pocket maximums.
These days it's not uncommon to see these numbers approach amounts needed to buy a small new car.
Another fun "new normal" are price swings which have us shopping our plans more often than we care to. As the primary health plan providers to most Americans, employers have been forced to navigate these changes on behalf of their employees with few affordable options.
WE PROVIDE OPTIONS YOU'VE PROBABLY NEVER SEEN OR HEARD OF BEFORE!

Complete the form below, and one of our trusted advisors will reach out to help.
Click the "Group Contact Form" button to start

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Adoption & Employer Contribution Agreement TEST FORM - NOT YET APPROVED

To download a PDF version of this form click the [SHA Employer Agreement] button above.

Employer Name: *

Street Address: *

City: *

State: *

Zip: *

Billing address same:

Yes

No

Billing Street Address:
Not required if billing address is same.

City:
Not required if billing address is same.

State:
Not required if billing address is same.

Zip:
Not required if billing address is same.

Tax ID Number: *

Name: *
Authorized Representative (Company Officer)

Title: *
Authorized Representative (Company Officer)

Phone: *
Authorized Representative (Company Officer)

Email: *
Authorized Representative (Company Officer)

Name: *
Billing Contact (Not required if same as Authorized Representative above.)

Title:
Billing Contact

Phone:
Billing Contact

Email:
Billing Contact

Name: *
Benefits Contact (Healthcare Facilitator) Not required if same as Authorized Representative above.

Title:
Benefits Contact (Healthcare Facilitator)

Phone:
Benefits Contact (Healthcare Facilitator)

Email:
Benefits Contact (Healthcare Facilitator)

Business Type: *

Nature of Business: *

SIC Code:
If you need help: https://www.naics.com/search/

Year Established

Number of Full-Time Employees: *

Number of Part-Time Employees: *

Website/URL
Company Website

Payroll Frequency: *

Company Name on Checking Account: *
Note: Required to document where ACH payments will come from.

Bank: *
Note: Required to document where ACH payments will come from.

Routing Number: *
Note: Required to document where ACH payments will come from.

Account Number: *
Note: Required to document where ACH payments will come from.

Employee Class 1: *
Define employee classes | example: Managment, >10 years, etc. (If no classes: ALL)

Employee Class 2:

Employee Class 3:

Eligibility: *

Full-Time: Must work at least ____ hours per week. *

Coverage Effective 1st of the month following: *

Desired Effective Date: *

Open Enrollment Start: *
Annual Plan changes can be made beginning this date.

Open Enrollment End: *
Annual Plan Changes can be made until this date.

Plan to be offered: *

Sedera IUA to be offered: *

Healthy Essentials Dental/Vision to be offered: *

Employer Contribution Strategy: *

Employee Contributions will be paid by: *
Name & Title of the person making payroll deductions.

Name, Title and Email of Authorized Company Representative *
Bill.com, Inc Acknowledgment:
Answers will be emailed for authorization. By my affirmative email reply. I hereby authorize Bill.com, Inc., on behalf of Shared Health Alliance (SHA), to initiate entries to the bank accounts that I enter, or enable SHA to enter, on the Bill.com, Inc. web site [in order to pay amounts that I owe] to SHA in accordance with instructions entered by SHA on the Bill.com web site] and, if necessary, to initiate adjustments for any transactions credited or debited in error. I represent that I have authority to bind the organization that owns the bank accounts, and to authorize all transactions to the bank accounts that are initiated through Bill.com, Inc. I acknowledge that transactions initiated to the bank accounts must comply with the provisions of U.S. law. This authorization will remain in effect until the organization notifies Bill.com, Inc. in writing to cancel it in such time as to afford Bill.com, Inc. and the bank reasonable opportunity to act.

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Employers

Complete the form below, and one of our trusted advisors will reach out to help.Click the "Group Contact Form" button to start

Adoption & Employer Contribution Agreement ****TEST FORM - NOT YET APPROVED****

Complete the form below, and one of our trusted advisors will reach out to help.
Click the "Group Contact Form" button to start

Adoption & Employer Contribution Agreement TEST FORM - NOT YET APPROVED