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STAFF REPORT
Administrative Services Department
DATE: August 18, 2015
TO: Honorable Mayor and City Council
FROM: Hue C. Quach, Administrative Services Director
By: Jeannette Flores, Human Resources Administrator
Sarah Campbell, Senior Human Resources Analyst
SUBJECT: AGREEMENT TO PURCHASE FIRST PACIFIC EXCHANGE INC., DBA
NAVIGATEHCR, SOFTWARE AND RELATED SERVICES FOR
AFFORDABLE CARE ACT TRACKING AND IRS REPORTING IN THE
AMOUNT OF $8,388
Recommendation: Approve
SUMMARY
Beginning January 1, 2015, large employers are subject to potential penalties if they fail
to comply with new tracking and reporting requirements with the Internal Revenue
Service ( "IRS "). The reporting provides the IRS with information it needs to enforce the
Individual Mandate and the Employer Mandate under the Affordable Care Act ( "ACA ").
The First Pacific Exchange Inc., dba NavigateHRC, software system will help collect
and aggregate the data necessary to manage these requirements and will help
minimize potential penalties.
It is recommended that the City Council authorize and direct the City Manager to
execute an agreement to purchase First Pacific Exchange Inc., dba NavigateHCR,
Software and related services for Affordable Care Act tracking and IRS reporting in the
amount of $8,388.
BACKGROUND
On February 10, 2014, the Department of Treasury issued final regulations on the ACA.
Beginning January 1, 2015, employers with 50 or more full -time employees are required
to comply with new annual IRS tracking and reporting requirements. The reporting
provides the IRS with information it needs to enforce the Individual Mandate, which
requires individuals to obtain health coverage, and the Employer Mandate, which
requires large employers to offer health coverage to employees working, on average, 30
or more hours per week. Employers who fail to meet these requirements are subject to
potential penalties.
Purchase of NavigateHCR Software Solution for ACA Tracking and Reporting
August 18, 2015
Page 2 of 4
Under the ACA, there are three types of monetary penalties that the IRS can levy
against the City. The first penalty is failing to offer substantially all of its full -time
employees minimum essential health coverage; the second penalty is for failing to offer
health coverage to employees who work an average of 30 hours or more per week; and
the third penalty is failing to properly submit and complete the required IRS reporting
forms. These penalties can range from $100 for each day an employee is not offered
coverage up to a maximum of $1.5 million in reporting requirements.
In January, the City began tracking hours for approximately 150 part -time employees to
monitor their eligibility under the ACA. This process requires staff to manually track and
calculate each employee's hours and eligibility status based on their initial
measurement period and standard measurement period. The initial measurement
period is based on an employee's hire date and runs 12 months from their date of hire.
The standard measurement period is a "Look Back Measurement Period" which is from
December 2014 through November 2015. There are specific legal restrictions regarding
the timing and length of the periods, so the City has no control over the dates selected.
The City must also follow various rules to calculate hours of service under these
measurement periods to determine whether a particular employee is considered full -
time under the ACA during the 2015 stability period. This process is currently completed
by utilizing a combination of manual reports, spreadsheet applications, and Sungard
Pentamation (Pentamation), the City's existing financial accounting system software.
Pentamation does not have the mechanism to generate the IRS reports needed to
comply with the Individual Mandate. The first reporting deadline will be on February 28,
2016; however, the annual reporting will be based on the data collected in 2015. Staff
will need to manually collect data for approximately 450 employees by using an Excel
spreadsheet and manually complete approximately 900 standardized IRS forms by
specifically inserting information that will be required in each field.
DISCUSSION
Due to the complexity of the new tracking and reporting requirements and limited
capability with Pentamation, the City conducted a Request for Proposal ( "RFP ") to
address the necessity for a system that would help collect and aggregate the data
necessary to manage the ACA, monitor potential penalties, and populate the required
IRS reports. In June 2015, the City received six proposals. The City reviewed the
proposals and participated in on -line tutorials to view the system first hand. Each
proposal was evaluated and ranked based on overall experience with the ACA,
compatibility with Pentamation, demonstration of the proposed system, and cost. Their
ranking and proposed costs are listed below:
Purchase of NavigateHCR Software Solution for ACA Tracking and Reporting
August 18, 2015
Page 3 of 4
Rank
Firm
First Year Costs
Subsequent Years Cost
1.
NavigateHCR
$8,388
$7,188
2.
Worxtime
$4,795
$4,000
3.
Equifax
$29,340
$14,340
4.
UnifyHR **
$17,142
$9,392
5.
Health eft)
$22,100
$13,300
6.
Continuous
$23,600
$14,100
Health
* *During
the RFP process,
UnifyHR notified us
they would no longer be accepting
clients with less than 2,500 employees.
NavigateHCR's proposed ACA software system was rated first among the three
companies. Although the costs are higher than the second rated system,
NavigateHCR's capability and ease of use justified the higher price. Most specifically,
the system will also generate the IRS reports required in 2016, which was not included
in the proposals with the other two companies.
NavigateHCR's ACA software solution will also remain up to date with legislative
changes of the ACA and will help ensure compliance by providing the following
features:
• Eligibility Tracking: The platform will aggregate the necessary data from any
source to track hours, determine eligibility, predict future enrollment volume, and
provide alerts for potential compliance risk.
• IRS form preparation and distribution: NavigateHCR will collect payroll,
benefits, leave, and other required data from the uploaded information and
translate the data into the appropriate indicator codes to populate the forms
required by the IRS, which can lead to fewer manual errors.
• Compliance reporting and analytics: NavigateHCR offers compliance
awareness reports and alerts to help avoid costly penalties. Ensuring information
is relayed accurately to the IRS and in a timely manner is imperative because
fines are assessed monthly.
• Complete Audit Trail: NavigateHCR provides comprehensive audit trails in case
of a follow -up investigation by the Department of Labor.
• Adapting to Changes: The calculations, models, and reports are updated as
new provisions to the ACA are rolled out, minimizing compliance risks.
The new software system will provide a more efficient process when it comes to
tracking employee hours and eligibility. The system will also ensure the proper
population and filing of all required IRS forms and other federally required notices so
that the City can remain in compliance with all ACA regulations and avoid costly
penalties. The manual labor in tracking affordability and the different measurements
periods for employees is very labor intensive and would cause a greater chance of
Purchase of NavigateHCR Software Solution for ACA Tracking and Reporting
August 18, 2015
Page 4 of 4
incorrect reporting. NavigateHCR's background and competency were investigated, and
it was concluded that they could satisfactorily provide the services that were specified
by the Administrative Services Department's needs.
FISCAL IMPACT
The cost to purchase and implement the new software system is $8,388. Subsequent
annual costs of $7,388 would be necessary for NavigateHCR's software upgrades and
comprehensive reporting services. Future year's costs will be budgeted as part of the
annual budget adoption process.
RECOMMENDATION
It is recommended that the City Council authorize and direct the City Manager to
execute an agreement to purchase First Pacific Exchange Inc., dba NavigateHCR,
Software and related services for Affordable Care Act tracking and IRS reporting in the
amount of $8,388.
Approved.
Dominic Lazzartd
CI y Manager
Attachment: Proposed Agreement with First Pacific Exchange Inc., dba NavigateHCR
navlgateHCR
.,
AGREEMENT FOR SERVICES
This Agreement, dated as of , 201_ ( "Effective Date "), is between FIRST PACIFIC EXCHANGE, INC,
doing business as NavigateHCR ( "NavigateHCR "), a California corporation with a principal place of business at 10875
Rancho Bernardo Road, Suite 108, San Diego, CA 92127, and the Employer listed in the Enrollment Form attached hereto.
I. SCOPE OF SERVICES AND PRICING.
1, Services. During the Term (as hereinafter defined), NavigateHCR will provide the Healthcare Reform Compliance
Services selected by Employer in Exhibit A as more fully described in this Agreement, in order to ensure that Employer
is in compliance with the Affordable Care Act and the Internal Revenue code regulations pertaining thereto.
EmployER Express:
• Monthly email that goes to the Employer Contact for download and disbursement to employees
• Notices from Department of Labor, Health and Human Services and IRS. These notices are part of the Affordable
Care Act's requirement that employers are responsible for providing their employees with any and all notices that
relate to their health benefits.
• Can be sent to company specific email or personal
EmployEE Express:
• Monthly email that goes to the Employees
• Notices from Department of Labor, Health and Human Services and IRS. These notices are part of the Affordable
Care Act's requirement that employers are responsible for providing their employees with any and all notices that
relate to their health benefits.
• Employee verifies and acknowledges email
• For employees that do not have email, packet can be created in English and Spanish and delivered to the Employer
for paper delivery. Additional fulfillment charges may apply for Employee mailings.
• Monthly compliance report to Employer
Summary Plan Description Wrap (ERISA BOOST):
• Preparation of "wrap" document and Summary Plan Description
• Compliance with ERISA and ACA related to welfare benefit plans
Testing:
• Two tests as applicable per client
• Employer on- boarding and discovery process identifies appropriate tests
Additional Testing:
• Additional testing is available for each client
• Potential tests include the following: Affordability Safe Harbor, Tax Reporting (Simplified or General), Transiti
Relief, MEC/MVP Coverage, Significant Ownership, Cadillac, W2 and Measurement Periods.
Tracker for Variable FTE.
• Tracking of the hours of variable hour employees so that Employer can determine which employees need to be
offered benefits
• Monthly reporting tool that allows Employer to monitor their variable hour employee status.
Tracker — Quarterly (IRS Reporting):
• Monitor Employer's employees hours on a quarterly basis to get the company ready for IRS filings of 6055/6056
Reporting back to Employer related to any data issues or repair requirements
• Data repository that facilitates year end filings
Data Testing & Auditing.
• Validation of General and Simple IRS Reporting
• Filing of applicable 1094 -B, 1095 -8, 1094 -C and 1095 -C
• PDF file to Employer of individual employee forms
• Filing services will be provided in conformity with IRS rules and regulations
1095 Form Fulfillment to Employees Home Address:
• Mail completed form to Employee Home Address
• Return mail back to Employer address
ACA Concierge Service:
• Educational phone and email line for Employer
• Response time on phone calls and emails will be within 24 business hours
• Access to phone and /or email
• Answered by HR support with 10+ years of experience and/or Benefit Account Managers with also 10+ years of
experience
In addition to these services above, Navigate HCR will receive and respond to any and all questions from the IRS on behalf
of the Employer. Promptly after execution of this Agreement, NavigateHCR will schedule an implementation meeting or
conference call with Employer.
2. Pricing and Payment Terms. Pricing for the Services selected by Employer shall be as set forth in Exhibit A. The one-
time set -up fee shall be due and payable upon execution of this Agreement and submission of invoice. Other recurring
charges shall be due. Employer may choose to pay for the Services rendered hereunder by credit card by completing
and returning to NavigateHCR the Credit Card Option Form attached hereto.
II. Terns of Agreement; Termination
I . Term. This Agreement shall commence on the Effective Date and shall continue for a period of one year thereafter (the
"Initial Term "), unless sooner terminated in accordance with the provisions of Section I1.2 below, it being understood
and agreed that the Services provided hereunder shall apply to the ACA reporting period commencing January 1, 2015.
After the Initial Term, this Agreement shall renew for successive one -year period (each a "Renewal Term ") and
collectively with the Initial Term, the "Term "), on the same terms and conditions, unless and until either party gives
written notice of non - renewal at least thirty (30) days prior to expiration of the then current Term.
2. Termination. Either party may terminate this Agreement at any time if i) the other party breaches
warranties or obligations hereunder and such breach has not been cured within thirty (30) da itten notice
the nature of the breach (if the breach is not of a nature capable of cure, termination shall ctive upon wri n nom
(ii) either party attempts to assign this Agreement or any obligation hereunder other party's con t, except'
otherwise allowed hereunder; or (iii) any assignment is made of the other party's b for the benefit o reditors, or if
petition in bankruptcy is filed by or against the other party (unless an involuntary filing and such fling is dismissed within
30 days of such filing), or if a receiver or similar officer is appointed to take charge of all or part of the other party's property,
or if the other party is adjudicated a bankrupt.
3. Either party may terminate this Agreement, effective immediately, if (i) the other party is named as a defendant in a
criminal proceeding for a violation of H finding IPAA or other security or privacy laws or (ii) a or stipulation that the
other party has violated any standard or requirement of HIPAA or other security or privacy laws is made in any
administrative or civil proceeding in which the party has been joined.
4. Upon termination of this Agreement for any reason, NavigateHCR shall return and destroy all PHI received from
Employer (or created or received by NavigateHCR on behalf of Employer) that NavigateHCR still maintains in any form,
and shall retain no copies of such PHI or, if return or destruction is not feasible, it shall continue to extend the protections
of this Agreement to such information, and limit further use of such PHI to those purposes that make the return or
destruction of such PHI infeasible.
111. Representations and Warranties
NavigateHCR acknowledges that Employer is entering into this Agreement based on its representation that its Chief
Executive Officer, Dr. Kristin Kahle, is an expert in ACA compliance. NavigateHCR represents and warrants that all
Services hereunder will be provided by, or under the supervision of, Dr. Kahle. NavigateHCR, and its employees and
agents if any, have the knowledge, experience and skill necessary to perform the Services in a manner consistent with
the level of care and skill possessed by the most experienced and skilled professionals providing services comparable to
the Services. NavigateHCR has the licenses, permits and other governmental authorizations necessary to perform the
Services in compliance with all applicable federal, state and local laws, rules and regulations. Neither NavigateHCR nor
any of its employees or agents is bound by any contract, agreement, instrument, judgment, decree or other restriction of
any nature whatsoever limiting their respective right or ability to enter into this Agreement or to carry out its terms,
including, without limitation, the performance of the Services; the execution and delivery of this Agreement, and the
performance by NavigateHCR and its employees and agents of their obligations hereunder, will not result in any violation
of, or conflict with, or constitute a default under any contract, agreement, instrument, judgment or decree, including,
without limitation, any confidentiality and non - compete clauses contained therein. NavigateHCR shall use its best efforts
in the performance of the Services and shall perform the Services diligently and conscientiously.
IV. Confidentiality Obligations.
NavigateHCR acknowledges that, in connection with the Services to be provided hereunder, it will receive confidential
information of Employer and its employees, including health information and other personal information, including
social security numbers (collectively "PHI "), that may be protected under Federal, State and local privacy laws and
regulations, including without limitation the Health Insurance Portability and Accountability Act of 1996, as amended
( "HIPAA "), 45 CFR Parts 160 and 164 (the "Privacy Rule "), and 45 CFR Parts 160, 162 and 164 (the "Security Rule ").
NavigateHCR may use and/or disclose PHI received by employer pursuant to this Agreement solely in connection with
the performance of Services hereunder and in compliance with the Privacy Rule and Security rule, as applicable.
NavigateHCR shall not use or further disclose CE's PHI otherwise than as permitted or required by this Agreement or
as required by law. NavigateHCR shall use appropriate safeguards to prevent use or disclosure of PHI otherwise than as
provided for by this Agreement. NavigateHCR shall maintain a comprehensive written information privacy and security
program that includes administrative, technical and physical safeguards appropriate to the size and complexity of
NavigateHCR' s operations and the nature and scope of its activities.
2. NavigateHCR shall report to Employer any use or disclosure of PHI otherwise than as provided for by this Agreement
of which NavigateHCR becomes aware. NavigateHCR shall ensure that any agents, including subcontractors, to who
it provides PHI received from (or created or received by NavigateHCR on behalf of) Emplo er agree to the
restrictions and conditions that apply to NavigateHCR with respect to such PHI.
3. During the Term of this Agreement, NavigateHCR shall notify Employer within itwenty- fo ou rs of any or actual breach of security, intrusion or unauthorized use or disclosure of Pnd/ actual or susp ted us disclosure of data in violation of any applicable federal or state laws or regulati igateHCR shall a (i) pror. corrective action to cure any such deficiencies and (ii) any action pertaining to authorized disc re required
applicable federal and state laws and regulations.
4. Employer shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and
security of PHI transmitted to NavigateHCR pursuant to this Agreement, in accordance with the standards and
requirements of Federal, State and local privacy laws and regulations, including HIPAA, until such PHI is received by
NavigateHCR.
From time to time upon reasonable notice, upon a reasonable determination by Employer that NavigateHCR has breached
this Agreement, or to the extent that Employer determines that such examination is necessary to comply with EmpIoyer's
legal obligations pursuant to privacy laws relating to certification of its security practices Employer may inspect the
facilities, systems, books and records of NavigateHCR to monitor compliance with this Agreement. NavigateHCR shall
promptly remedy any violation of any term of this Agreement and shall certify the same to Employer in writing. The
fact that Employer inspects, or fails to inspect, or has the right to inspect, NavigateHCR's facilities, systems and
procedures does not relieve NavigateHCR of its responsibility to comply with this Agreement, not does Employer's (i)
failure to detect or (ii) detection, but failure to notify NavigateHCR or require NavigateHCR's remediation of any
unsatisfactory practices constitute acceptance of such practice or a waiver of Employer's enforcement rights under this
Agreement.
6. The parties acknowledge that state and federal laws relating to electronic data security and privacy are rapidly evolving
and that amendment of this Agreement may be required to provide for procedures to ensure compliance with such
developments. The parties specifically agree to take such action as is necessary to implement the standards and
requirements of HIPAA, the HIPAA Regulations and other applicable laws relating to the security or confidentiality of
PHI. The parties understand and agree that Employer must receive satisfactory written assurance from NavigateHCR
that NavigateHCR will adequately safeguard all PHI that it receives or creates pursuant to this Agreement. Upon
Employer's request, NavigateHCR agrees to promptly to enter into negotiations with Employer concerning the terms of
an amendment to this Agreement embodying written assurances consistent with the standards and requirements of
HIPAA, the HIPAA Regulations or other applicable laws. Employer may terminate this Agreement upon thirty (30)
days written notice in the event (i) NavigateHCR does not promptly enter into negotiations to amend this Agreement
when requested by Employer pursuant to this Section or (ii) NavigateHCR does not enter into an amendment to this
Agreement providing assurances regarding the safeguarding of PHI that Employer, in its reasonable discretion, deems
sufficient to satisfy the standards and requirements of HIPAA and other privacy laws and regulations.
7. Subject to Employer's timely payments and adherence to these terms and conditions, upon execution of this Agreement
and enrollment NavigateHCR grants Employer permission to use and distribute only to its employees, NavigateHCR 's
materials, pamphlets, brochures, emails and /or other compliance documents ( "Compliance Materials ") sent by
NavigateHCR to Employer pursuant to this Agreement. Employer will keep in confidence, and prevent the disclosure of
any and all Compliance Materials sent by NavigateHCR to Employer, to any person or persons outside its organization,
except that Employer shall have the right to review and disclose such Compliance Materials with its insurance brokers
and outside counsel. Employer shall take safeguards to ensure that any employees or other persons authorized to receive
NavigateHCR' s materials, also comply with this Agreement and do not disseminate said materials to persons outside of
its organization, other than for personal use. Employer shall be jointly and severely liable for the breach of this Agreement
by any employee or agent receiving the Compliance Materials. Such information is considered proprietary, confidential
information that is subject to protection of intellectual property laws, including without limitation, copyright. Thus, it is
imperative that this Agreement is strictly adhered to and NavigateHCR' s proprietary information is not disseminated to
third parties who have not paid for the materials and information. The foregoing notwithstanding, nothing herein
contained shall preclude Employer or any of its employees from using or disclosing any information which is: (a) now,
or hereafter becomes, through no act or failure to act on the part of the Employer, publicly known or available, or is not
protected by any valid copyright or other intellectual property right; (b) known to the Employer prior to the time of its
original disclosure by NavigateHCR, as shown by competent evidence to establish such knowledge; (c) herea
furnished to Employer by a third party, as a matter of right and without breach of any obligation wed to Navi ate ,
as shown by competent evidence to establish such disclosure; (d) independently developed by
breach of this Agreement, as evidenced by competent-written proof, or (e) the subject of a w ' rmission
provided by NavigateHCR.
V. INDEMNICATION AND INSURANCE.
1. Indemnification by NavigateHCR. NavigateHCR agrees to defend, indemnify and hold Employer, its shareholders,
directors, officers, employees, agents and affiliates harmless from all claims, suits, costs, losses and damages, including
without limitation reasonable attorneys' fees, to the extent arising in whole or in part out of or in connection with any (i)
negligent acts or omissions of NavigateHCR, its employees or agents ' including without limitation professional errors
and omissions, (ii) violation of laws or regulations by NavigateHCR__, its employees or agents or (iii) breach of this
Agreement by NavigateHCR.
2. Indemnification by Employe Employer agrees to defend, indemnify and hold NavigateHCR, its shareholders,
directors, officers, employees, agents and affiliates harmless from all claims, suits, costs, losses and damages, including
without limitation reasonable attorneys' fees, to the extent arising in whole or in part out of or in connection with any (i)
negligent acts or omissions of Employer, its em 1p_oyees or agents, (ii) violation of laws or regulations by Employer,
its employees or agents or (iii) breach of this Agreement by Employer.
3. Indemnification Notice. In the event an indemnifiable claim is made, the indemnified party shall give the indemnifying
party prompt written notice of any such claim as and when the indemnified party learns of the same, and shall provide
the indemnifying party with all reasonable information and assistance; provided, however, that the indemnified party's
failure to provide timely notice of any claim shall not in any way affect the obligation to indemnify so long as the
indemnifying party has not been materially prejudiced by such failure to give timely notice. The indemnifying party shall
have the right, at its sole expense, to direct and control the defense and /or settlement of any such claim, but the
indemnified party shall have the right to monitor the case or claim through its own counsel and at its own expense, and
to approve any settlement that does not include a full and unconditional release of the indemnified party.
4. Insurance. During the Term of this Agreement, NavigateHCR shall maintain professional liability insurance and
cybersecurity insurance on a claims made basis, from the Effective Date and for a three -year period following the
completion of the Services.
VI. MISCELLANEOUS.
1. Notices. Except as otherwise provided herein, all notices or other communications to be given or that may be given by either
party to the other shall be deemed to have been duly given when made in writing and delivered in person, one business day
after being sent by recognized overnight courier or three days after deposit in the United States mail, certified, postage prepaid,
return receipt requested and addressed as follows:
To NavigateHCR: To NAME OF CLIENT: CITY OF ARCADIA
NavigateHCR
10875 Rancho Bernardo Road, Suite 108 Address 240 W. Huntington Drive
San Diego, CA 92127 City, Sate, Zip Arcadia, CA 91007
Attention: Dr. Kristin Kahle Attention: :Hue Quach, Administrative
Email: Kristin @navigatehcr.com Email: Services Director
hgpach @AxcadiaCA.gov
The address to which notices or communications may be given to either party may be changed by written notice given by one
parry to the other pursuant to this section.
2. Injunctive Relief. Both parties acknowledge that any use or disclosure of the other party's confidential information in a manner
inconsistent with the provisions of this Agreement may cause the disclosing party irreparable damage for which rem d'
other than injunctive relief may be inadequate, and both parties agree that the disclosing party may request injunctive or
equitable relief seeking to restrain such use or disclosure.
3. Waivers and Amendments. Waiver by either party of any default by the other party shall not ed a waiver of
default. No provision of this Agreement shall be deemed waived, amended or modified er party, unless c
amendment or modification is in writing and signed by an authorized representativ party.
4. SeverabdLN. If any provisions, or any portion of any provision, contained in this Agreement is determined to be invalid under
any statute or rule of law, then it shall, to that extent alone, be deemed omitted, and the remainder of this Agreement shall
remain in full force and effect.
5. Entire Agreement. This Agreement constitutes the entire agreement between the parties with respect to the subject matter
hereof, and supersedes all prior agreements, understandings, proposals and communications, oral or written, regarding such
subject matter.
6. Counterparts. This Agreement may be executed in any number of counterparts, each of which shall be deemed to
be an original, but all of which together shall constitute one agreement. Facsimile signatures shall have the same force
as originals.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their respective duly authorized
representatives as of the Effective Date.
FIRST PACIFIC EXCHANGE, INC. NAME OF CLIENT
dba NavigateHCR CITY OF ARCADIA
IN
Name:
Title:
I:
Name: Dominic'Lazzaretto
Title: City Manager
APPROVED AS TO FORM:
Stephen P. Deitse
City Attorney
Enrollment Form
Employer Information
Company Name:
Address:
Company Phone: Fax:
Primary Contact (Employer Contact Receiving Notices and Reports)
Name: Title:
Phone: Email:
Secondary Contact
Name: Title:
Phone: EEmail:
Broker /Facilitator Contact
Name: Company Name:
Phone: Email:
Address:
,�- nawrigateHCR
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E, IIIBfl' A
PR[CINC AND SERVICE PACKAGE
PRODUCTS
Company Size
Monthly Fee
One -time Fee
Optional Per Form Fee
ACA Eligibility &
Compliannce
Tracking & Alerts
Set -up Fee:
Including One-
time Exposure
Anal tics
1094/1095IRS
Electronic
Generation ER /EE
$0.50 perform
1094- C/1095 -C IRS
Electronic Form
Fulfillment
(includes
Disclosure
$3.50 per form
* Service package assumes a minimum of 12 months of employer continuous participation
** Optional Services may be cancelled at any time by Employer upon written nonce to NavigateNCR prior to commericerncnt of
Optional Services.
/ navigateHCR.com
Credit Card Option
Monthly Bank Draft
Billing Name: Billing Title:
BillingAddress:
Phone: :Frna i1: —
CM Master Card
Visa
0 AmEX
— I
ACH Debit Authorization Option
Monthly Bank Draft
Bank Name:
bank Address:
Bank Phone Number:
ABA Number (9 Digits):
Name on Card:
Card Number:
NameonAccount: Phone:
Savings El' Checking El'
Month Transaction to Begin:
Account Number:
This authorization is to remain in full force and effective until Navigate HCR has received WRITTEN notification from the policyholder of its termination of the
payment agreement.
Authorized by:
Phone Number:
Email Address:
Print Name:
Signature:
Completed application can be faxed or emailed.
Tax: Attention NavigateHCR Billing, (858) 408 -9250 1 Email: newbusiness a:navigateher.com
Fax: Attention NavigateHCR Billing, (858) 408 -9250 1