ACA Reporting Quote Request Please fill out the following information below. Note: All fields are required. Company Name Address City State Zip Total # of EIN's Company Contact Name Contact Phone Contact Email Fully InsuredSelf Insured Do you have Employees residing in any of the following states? (select all appropriate) CaliforniaNew JerseyRhode IslandWashington DC For Calendar Year 2020, did you offer an ICHRA (Individual Coverage HRA) to any group of employees? YesNo Brokerage Firm Brokerage Contact Name Brokerage Contact Email
