POP Plans
	Discrimination Data Form To capture information for non-discrimination testing. Spreadsheet A must be completed. , 2 Pages (Rev. 2007)
	POP Application Provides employer, contact & broker information to Conexis for account set-up., 2 Pages (Rev. 09/06)
	POP Service Agreement 10 Pages

COBRA & COBRA HIPPA Plans
	CONEXIS ADMINISTRATIVE SERVICES AGREEMENT 10 Pages
	Employer Kit Client Profile – is the Employer Application COBRA and HIPAA Attachment – provides information about current COBRA obligations Carrier and Plan Information Form – provides information about current carrier plans Division Contact Form – required only when client has additional reporting divisions , 5 Pages
	Sales Implementation Transmittal Form (Client Pay) For COBRA or COBRA HIPAA plans. Provides agent information to Conexis & indicates that fees will paid by the employer. , 1 Page (Rev. 5/06)

FSA/Reimbursement Plans
	Administrative Services Agreement 11 Pages (Rev. 2011)
	Discrimination Data Collection Form Collects data for non-discrimination testing purposes. Can be submitted at time of submission or at time of group enrollment. , 2 Pages
	FSA Employer Kit 8 Pages
	New Business Application Fee Appendix must be returned with signature and initials next to services for which the group is contracting., 7 Pages (Rev. 3/06)
	Sales Implementation Transmittal Form (Client pay) Provides agent information to Conexis & indicates that fees will paid by the employer. , 1 Page (Rev. 05/06)

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For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com