POP Plans
	Discrimination Data Form To capture information for non-discrimination testing. Spreadsheet A must be completed. , 3 Pages
	POP Application Provides employer, contact & broker information to Conexis for account set-up., 1 Page (Rev. 09/06)
	POP New Business Application The Master Application. Includes fee schedule., 10 Pages (Rev. 01/07)
	Sales Implementation Transmittal Form (Client Pay) Provides agent information to Conexis & indicates that fees will paid by the employer. , 1 Page (Rev. 05/06)

COBRA & COBRA HIPPA Plans
	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
	New Business Application for COBRA or COBRA HIPAA Services Page 4 is a client signature page. , 9 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)
	Service Agreement Appendix with Fee Schedule for COBRA or COBRA HIPAA Services Client must sign and place initials next to services being purchased., 4 Pages

FSA/Reimbursement Plans
	Administrative Services Agreement Must be signed on page 4., 9 Pages (Rev. 3/06)
	Discrimination Data Collection Form Includes Spreadsheet A & B. Collects data for non-discrimination testing purposes. Can be submitted at time of submission or at time of group enrollment. , 3 Pages
	FSA Employer Kit Bundles these forms: Client Profile – is the employer application. Reimbursement Account Attachment Form – Gathers info to generate plan documents and the SPD. Banking Options Form – Gathers banking info to allow Conexis to withdraw funds to facilitate claims payment. Option #1 is preferred. ACH Debits Form – Authorizes Conexis to perform weekly sweeps on client account for claims payment. , 5 Pages (Rev. 4/06)
	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