Case Build Implementation Checklist

This form has 8 pages; please use the NEXT button in the bottom purple bar to go to the next page. After submitting the form, please upload email these supporting documents to your Broker Builder Solutions sharefile folder. https://brokerbuildersolutions.sharefile.com

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Holiday Calendar (Only applicable if setting up PTO)
Premium Contribution Worksheet
Census Template
Any Plan Summaries or other Documentation that you would like loaded into the Portal

You should only complete the sections of the checklist that are applicable to the products being implemented. Please contact your dedicated Analyst if you have questions.

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Case Build Implementation Checklist

PLEASE NOTE: THIS FORM WILL AUTOSAVE YOUR ANSWERS AS LONG AS YOU ARE USING THE SAME BROWSER WHEN YOU RETURN TO THE FORM

Enrollment Platform Type*

If "Other" selected above, please enter platform type:

Company Name*

Company Full Address*

Company Main Phone Number

Company TAX ID#*

Company SIC Code*

Benefits Eligible Monthly Hour Minimum

Number of Benefit Eligible Lives

Client Primary Contact - First Name*

Client Primary Contact - Last Name*

Client Primary Contact - Email Address

Client Primary Contact - Phone

Broker Point of Contact - Name (Post-implementation)*

Broker Point of Contact - Email Address*

Broker Point of Contact - Phone

Please Select All Features/Enrollment Options to be Implemented*

Fields marked with an asterik (*) are Required

Group Structure

List all Benefit Classes & Pay Frequency

	Class	Pay Frequency
	Class	Pay Frequency
1	Class	Pay Frequency
2	Class	Pay Frequency
3	Class	Pay Frequency
4	Class	Pay Frequency
5	Class	Pay Frequency
6	Class	Pay Frequency

If eligibility, cost, etc… varies dependent based upon class, please provide an overview of the distinction below.

Benefit Entry, Waiting & Termination Rules

Benefit Entry Rule*

Hire Date

1st of Month following

1st of Month coinciding with

Other

Write here

Benefit Waiting Period*

0 Days

30 Days

60 Days

Other

Write here

Benefit Termination Rule*

Employment Termination/Event Date

End of Month

Other

Write here

Rehire Eligibility Rules

Rehire rules bypass the waiting period and define different entry date rules for employees who are terminated then rehired with a specified period. When these are not set, or if the employee is outside of the rehire period, the new hire eligibility rules will apply.

NOTE: If you skip this Section there will be no Rehire Rules built into site.

Rehired within

0 Days

30 Days

60 Days

Other

Benefit Entry Rule (After Rehire Date)

Rehire Date

1st of the Month Following

1st of the Month Coinciding with

Other

Reinstate Coverage Grace Period

0 Days

30 Days

60 Days

Other

Demographic Change Rules

Note: This is a different waiting period/entry date rules for existing employees who become newly eligible for benefits due to a demographic change, i.e. class. When this is not set it will follow the new hire eligibility rules.

Demographic- Coverage Waiting Period*

0 Days

30 Days

60 Days

Other

Demographic- Coverage Begins/Entry Date (After Waiting Period)*

Change Effective Date

1st of Month Following

1st of Month Coinciding With

Other

List Offices, Divisions, Departments, Business Units, etc

Note: Business Units are used to file for multiple ALE members under ACA, please list tax id numbers associated w/ each Business unit if applicable

Office Name	State	County	Business Unit	Division	Dept
Office Name	State	County	Business Unit	Division	Dept
Office Name	State	County	Business Unit	Division	Dept
Office Name	State	County	Business Unit	Division	Dept
Office Name	State	County	Business Unit	Division	Dept
Office Name	State	County	Business Unit	Division	Dept

Payroll : For your chosen Payroll Groups, please provide First Pay Date of Calendar Year

	First Pay Date of Calendar Year
	First Pay Date of Calendar Year
Biweekly 26	First Pay Date of Calendar Year
Biweekly 24	First Pay Date of Calendar Year
Weekly	First Pay Date of Calendar Year
Semi-Monthly	First Pay Date of Calendar Year
Monthly	First Pay Date of Calendar Year

Is there a Payroll API being used?

Yes

If Yes, please list Payroll Vendor

Benefits : List All Benefits Offered

If group has Critical Illness, Voluntary Life, etc… you must advise if the plan is an issue age plan. If yes, are plans stacked or re-rated, and advise if spouse cost is based on employee age? Lastly, add original issue age pertaining to the CI plan.

Benefit(s): Use Button to Repeat the Section

Ancilliary & Voluntary Benefits Data Collection

Plan Information: Please provide plan specific and relevant information

(Please complete as much of this information as you are able. For information not provided, we will obtain from your Plan documents.)

	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Restrict Employees over age - Voluntary Life	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Restrict Spouses over age	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Dependent age not eligible	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Student age not eligible	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Benefit Type (% of weekly earnings/flat amt)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Benefit Type (Increments/Increments w/Multiple of Earnings Max/Multiple of earnings)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Benefit Type (Flat Amt/Multiple of Earnings/Multiple of Earnings plus or minus)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Benefits as a % of Weekly Earnings/% of Monthly Earnings/% of Earnings (specify amt)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
GI Type (Flat/Lesser of Flat or x Earnings)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Multiple of Earnings Max	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Rounding Value (Salary / Benefit)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Rounding Type	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Round to Nearest	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Minimum Weekly Benefit	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Maximum Weekly Benefit	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Require Enrollment	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Employer Contribution Type	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Employer Contribution Percentage	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Accident Waiting Period (days)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Sickness Waiting Period (days)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
LTD Waiting Period	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D
Benefit Period (weeks/age)	Short Term Disability	Long Term Disability	Voluntary Life	Life and AD&D

Additional Benefit Information - Life Products

Age Reduction for Group and Voluntary Life

From Age	To Age	% reduced by	Based on Original Benefit
From Age	To Age	% reduced by	Based on Original Benefit
From Age	To Age	% reduced by	Based on Original Benefit
From Age	To Age	% reduced by	Based on Original Benefit
From Age	To Age	% reduced by	Based on Original Benefit
From Age	To Age	% reduced by	Based on Original Benefit

Additional Benefit Information - Medical

Do you offer a Health Savings Account (HSA)?

Yes

If Yes, how often do you contribute?

Any New Hires pro-rated?

Yes

Are Employees allowed to decline?

Yes

Does the Employer contribute to the Plan

Yes

If Yes, please provide details:

Do you offer a Health Reimbursement Account?

Yes

If Yes, please provide contribution details, ie. $400 HRA

Do you offer a Defined Contribution?

Yes

If Yes, please provide contribution details:

Affordable Care Act (ACA)

Complete only if using the system for 1094/1095 reporting

Please provide name of Low-cost Medical Plan

If using Business Units to file multiple ALE Members, please list all with corresponding Tax ID Number

(Please skip if this information was already provided on Page 2 of the checklist)

Transition Relief, Line 22

Yes

Check All That Apply

Using Qualified Offer Method

Using Qualified Offer Method Transition Relief

Using Section 4980H Transition Relief

Using 98 Percent Method Transition Relief

Safe Harbor Selection : Check All That Apply

Note: If varies based on class, please identify applicable Class

W-2 Safe Harbor: The W-2 Safer Harbor uses the employee’s annual W-2 waves (Box 1 value) and treats coverage as affordable if the employee contribution for the year does not exceed 9.56% of the W-2 value.

Rate of Pay Safe Harbor: The Rate of Pay Safe Harbor uses the employee’s rate of pay and treats coverage as affordable if the employee contribution for the year does not exceed 9.56% of the employee's rate of pay.

Federal Poverty Line Safe Harbor: The Federal Poverty Line safe harbor uses the federal poverty line for the year ($12,060 in 2018), and treats coverage as affordable if the employee contribution for the year does not exceed 9.56% of the federal poverty line value.

ACA Classes: Check All Classes That Apply

Eligible - Always works 30 Hours

Ineligible - Employee will never work 30 hours

Variable Hour - Hours must be tracked to determine eligibility

Will you need to utilize the Hour Tracking Module?

If yes, please complete the ACA Import Hours Monthly Temp that will be available in the ACA only Data Collection Template

Yes

Paid Time Off (PTO)

Complete this section only if you are using the system for PTO Management

Can Employees enter the hours per day they would like to request off?

Yes

Can Employees take off on weekends?

Yes

N/A

Do you require Begin and End Times for Partial Day Request?

Yes

N/A

Select Type

Vacation

Sick

Personal

What is the first Accrual Date?

How are the Hours Accrued?

Periodic

Manually

Unlimited

For PERIODIC Accrual, please answer these questions:



How are Hours accrued (Annual, Monthly or Pay Day)?
Hours Given per Year:
Please provide additional Hours given at Anniversary (ie. after 5 yrs, employee gets additional 40 hrs)
Is there a New Hire Waiting Period: If yes, please provide the waiting period (ie. 90 days)
Can Employees accrue Hours or request and take Leave during their Waiting Period? (yes/no):
Can Employees go into the negative? (yes/no) If YES, how many hours?
What is the Max number of Hours that can be carried over into a new Year?
Can Employees submit request for more Hours than they accrue in a Year? If YES, how many Hours?

For MANUAL Accrual, please answer these questions:



What is the Max number of Hours that can be carried over into a new Year?

Please use this space to provide additional notes and any other helpful information:

Data Auditing*

It is highly recommended that clients have an audit/reconciliation process in place to audit and reconcile carrier invoices and enrollment data monthly. If no solution is in place, BBS will schedule a demonstration of the Data Validation Platform with the client after HR training to illustrate how the client may use our Data Validation Platform as a Self-Service audit solution. Should the client choose to subscribe to the platform, the cost associated with the subscription of the platform is the responsibility of the client unless otherwise indicated. Do you have an auditing solution in place?

Yes

How frequently does your organization audit/ reconcile enrollment data?*

If "Other" selected above, please provide a brief description:

Does your current solution include any of the following?*

If "Other" selected above, please provide a brief description:

Data Auditing Acknowledgements*

I authorize Broker Builder Solutions to introduce this client to the Data Validation Platform after HR training has been completed.

I understand that this demonstration is an introduction to the platform to educate the client on the importance of auditing their monthly invoices/data post implementation and provide a potential resource.

Authorization does not obligate the Agency or Client to subscribe to the Data Validation Platform. Subscribing to use the Platform is at the discretion of the client who will be billed directly should they opt to utilize the platform unless otherwise indicated by the Agency.

Do you agree with the above statements?

Yes

Terms and Conditions*

Agency Support Clients: Checklists received after the 25th of the month will count towards the next month.
By checking this box I agree to the Payment Terms and Conditions for these services as outlined in my Agency Support Contract and/or case set up form.

Terms of Service: Our Data Management Solutions products and services adhere to the Broker Builder Solutions Terms of Service. These terms may be accessed by clicking here.

Yes, I agree

Signature for Terms and Conditions*

Please enter your name here

Date*

You’re done! – Please press SUBMIT in the purple Bar to send the Form to us.

	Yes	No
	Yes	No
Onboarding*
Enrollment*
ACA Set Up (Additional Costs may apply)*
EDI (Additional Costs will apply)*
PTO Tracking (Additional Costs will apply)*

	Yes	No
	Yes	No
Is an ALE
Member of ALE Group
Fully-insured
Self-insured
Medical Plans provide Minimum Value
Medical Plans provide Minimum Essential Coverage

Case Build Implementation Checklist

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Case Build Implementation Checklist

Benefit Entry, Waiting & Termination Rules

Rehire Eligibility Rules

Demographic Change Rules

Onboarding Task

Choose the Tasks you would like to be active within the Portal. Please send us any documents that need to be uploaded along with any customized language. Note: Please skip this section if onboarding is NOT being implemented.

In the event that custom language is not provided, the Task(s) will be created with Standard Language.

Welcome

Electronic Signature

Address

I-9

W-4

State Withholding

Emergency Contacts

EEOC

Confidentiality Agreement

Custom Task(s): Use Button to repeat the Section

Benefits : List All Benefits Offered

Benefit(s): Use Button to Repeat the Section

Ancilliary & Voluntary Benefits Data Collection

Additional Benefit Information - Life Products

Additional Benefit Information - Medical

Affordable Care Act (ACA)

Paid Time Off (PTO)

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