Group Health Insurance Application - Alliance for Contractors
Empowering Excellence Through Strategic Partnerships

Group Health Insurance Application

Alliance Partnership Benefits

Through our strategic Alliance partnerships, we deliver competitive group health insurance rates and enhanced coverage options. Our integrated benefits administration platform streamlines enrollment management and ensures comprehensive employee benefits that support talent retention and regulatory compliance.

Company Information

Company Name:
Federal Tax ID (EIN):
Business Address:
City, State, ZIP:
Primary Contact:
Phone Number:
Email Address:
Industry Type:
Number of Employees:
Requested Effective Date:

Employee Enrollment Details

Eligible Employees:
Participating Employees:

Enrollment Categories:

Employee Only
Employee + Spouse
Employee + Children
Family Coverage
Coverage Tier Number of Employees Estimated Monthly Premium
Employee Only
Employee + Spouse
Employee + Children
Family Coverage

Plan Selection Options

Available Plans Through Alliance Partnership:

HMO Plan - Lower cost, network restrictions
PPO Plan - Higher flexibility, broader network
High Deductible Health Plan (HDHP) - HSA eligible
EPO Plan - No referrals required, network-based
Plan Type Deductible Copay Out-of-Pocket Max Monthly Premium
Alliance HMO Gold $500 $25 $3,000 $485
Alliance PPO Select $1,000 $30 $5,000 $625
Alliance HDHP Plus $2,500 N/A $6,000 $395
Alliance EPO Premium $750 $20 $4,000 $555

Employer Contribution Structure

Employee Premium Contribution:
______% or $______
Spouse Premium Contribution:
______% or $______
Dependent Premium Contribution:
______% or $______

Contribution Method:

Percentage of Premium
Fixed Dollar Amount
Composite Rating

Alliance Advantage:

Our partnership network enables flexible contribution structures and competitive employer rates. Take advantage of group purchasing power and streamlined administration through Alliance integration.

Compliance Requirements

ACA Compliance Confirmation:

Plan meets ACA minimum essential coverage requirements
Plan meets affordability safe harbor requirements
Plan provides minimum value as defined by ACA

ERISA and COBRA Requirements:

ERISA plan documents and SPD distribution confirmed
COBRA administration services requested
HIPAA privacy and security compliance confirmed
Plan Year:
Calendar Year ☐    Plan Year: ____________

Alliance Integration Benefits

  • Competitive Rates: Access to preferred pricing through Alliance partnerships with major carriers
  • Enhanced Coverage: Comprehensive plan options with additional benefits not available in standard market
  • Streamlined Administration: Integrated benefits management platform for enrollment and ongoing administration
  • Dedicated Support: Alliance benefits specialists for implementation and ongoing support
  • Compliance Assurance: Built-in compliance monitoring and reporting for healthcare regulations
  • Employee Resources: Online portal access and educational materials for improved utilization

Primary Use Cases

Employee Benefits Enhancement

Comprehensive health coverage options designed to attract and retain top talent while managing costs effectively through Alliance partnerships.

Regulatory Compliance

Ensure full compliance with ACA, ERISA, COBRA, and HIPAA requirements through integrated compliance monitoring and reporting systems.

Benefits Administration

Streamlined enrollment processes, automated premium billing, and simplified employee communications through Alliance technology platform.

Talent Retention Strategy

Competitive benefits packages that support employee satisfaction and reduce turnover through enhanced coverage options and employer contributions.

Group Purchasing Advantages

Leverage Alliance collective purchasing power to access premium coverage options at competitive rates typically reserved for larger organizations.

Employer Signature
Date: _______________
Alliance Representative
Date: _______________

Alliance for Contractors - Group Health Insurance Application

For questions or assistance, contact our Benefits Department at [email protected]