Billing Worksheet Employer Name Billing Address and Contacts Billing Name: Group Billing Administrator Premium Collection Agency (include Premium Collection Agreement) Billing Address: Payment Premium Past Due Billing Contact Name: Email Address: Phone # Payments Detail Discrepancies Notification 1) 2) 3) Billing Options Payroll Schedule Number of pay periods per year: First deduction date: Number of deductions per year: First bill due date: Bill Schedule: Arrears Advance Bill Delivery: Website Self-Bill Billed premium amount: Levelized over 12 months Actual amount of deduction Employee ID: Social Security Number Alternate Employee ID Billing Sort: Name Employee ID Multiple Billing Locations: No Yes If yes, will each location payment separately? (attach listing with location name and address) Will employees need to be listed by separate division on the billing statement? Payments and Remittance Payments remitted: After each deduction Monthly Other Payment Method: Website ACH/Wire Check Payment Detail Remitted: Website Electronic via email Paper Statement Select one: Credits Refunds Deduct from payment (self-bill) Refund overpayments to: Bill Credits Pre-tax Post-tax Summary Employee Detail Employer Billing Administrator Employee Management Missed Deductions Bill employee at home Rebill group Other Employee Request to Cancellation/Change: Transamerica will handle Refer to: Name: Email: Date Billing Information Completed: TEB-BA-120618
Billing Worksheet Employer Name Billing Address and Contacts Billing Name: Group Billing Administrator Premium Collection Agency (include Premium Collection Agreement) Billing Address: Billing Contact Name: Email Address: Phone # Payments Payment Detail Premium Discrepancies Past Due Notification 1) 2) 3) Billing Options Payroll Schedule Number of pay periods per year: First deduction date: Number of deductions per year: First bill due date: Bill Schedule: Arrears Advance Bill Delivery: Website Self-Bill Billed premium amount: Levelized over 12 months Actual amount of deduction Employee ID: Social Security Number Alternate Employee ID Billing Sort: Name Employee ID Multiple Billing Locations: No Yes If yes, will each location payment separately? (attach listing with location name and address) Will employees need to be listed by separate division on the billing statement? Payments and Remittance Payments remitted: After each deduction Monthly Other Payment Method: Website ACH/Wire Check Payment Detail Remitted: Website Electronic via email Paper Statement Select one: Credits Refunds Deduct from payment (self-bill) Refund overpayments to: Bill Credits Pre-tax Post-tax Summary Employee Detail Employer Billing Administrator Employee Management Missed Deductions Bill employee at home Rebill group Other Employee Request to Cancellation/Change: Transamerica will handle Refer to: Name: Email: Date Billing Information Completed: TEB-BA-120618
SmallGroupApp.docx