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Your Name
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Company Name
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Name of Client
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Number of FEINs (business tax IDs) for this Employer
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Health Plan Anniversary Date(s)
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Funding:
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Number of 1095-C Forms (This includes all eligible employees and retirees/Cobra (only if self funded)
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What is the lowest single monthly employee contribution for a health plan you offer? If some employees have different lowest cost plans offered to them (i.e. collective bargaining or by location) please indicate as well.
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Do you offer coverage to employees working less than 30 hours
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