Company Name  * EIN  * Address  * City  * State  * Zip Code  * Contact Name  * Phone Number  * Email Address Fax Number PHI Officer  * Principal Office Location (State)  * Employer Entity CorporationS CorporationLimited Liability CompanyProfessional CorporationPartnershipGovernmental EntityChurchNon-Profit Organization Family Medical Leave Act Employer (Is) subject to FMLA Employer (Is-Not) subject to FMLA Reimbursement Checks are to be cut by Employer based on a reportVantage FlexElectronic Fund TransferEmployer through payroll download   Ordering Rule HRA is paid before the FSA FSA is Paid before the HRA Plan Information New Plan Amendment and Restatement Start Date  * End Date  * Effective Date  * The first year is First year is not a short plan year First year is a short plan year Original Effective Date if this is a Restatement Eligible Class of Employees All employees eligible for the employers Group Health Insurance.Salaried Employees OnlyHourly Employees OnlyAll employees except those checked below. Excluded Employees Union Employees Leased Employees Part-time employees (see below) Part-time is how many hours per week Conditions for Eligibility Same as employers Group Medical Plan30 days following employment60 days following employment90 days following employment180 days following employment Entry Date Same as Employers Group Medical planFirst day of the month following requirements.First Pay period following RequirementsDate conditions for eligibility are met Contribution to be made by Salary reduction ONLYEmployer contributions ONLYBoth salary reduction and employer contributions Employer Contribution Amount Employer Contribution will be made At the beginning of the plan year.Pro rata each pay period. Salary Reductions shall include Group Insurance Premium Health FSA Dependent Care FSA Individually Owned Insurance Transportation Parking Health FSA Minimum Contribution  * Health FSA Maximum Contribution  * The overall salary reduction amount shall not exceed  * Salary Reductions shall be made: Weekly Bi-Weekly Semi- Monthly Monthly For each of the different Salary Reduction Periods please provide the first Contribution Date of the year Pre-tax Premium Types Health Insurance Group Term Life Dental Insurance Cancer Insurance Vision Insurance Accident Insurance AD&D Insurance Prescription Drug Coverage Are the health premiums elected above self-funded by the employer? Yes No Terminated Employees shall Cease contributions and reimbursements upon termination.Continue contributions and reimbursements for the remainder of the plan year. Allow Over The Counter Drugs (OTC) to be reimbursed? Yes No Accommodate Health Savings Account (HSAs). Limit the FSA to the following. N/A All Section 213 expenses are eligible.Post deductible expenses only ($1000 single / $2000 Family).Dental and Vision expenses only. Open Enrollment shall be Established by the Administrator in the last quarter of the year.30 days prior to the beginning of the new plan year.60 days prior to the beginning of the new plan year. Is automatic enrollment for insured benefits provided under this Plan? Yes No Participants who fail to sign a new Election Form shall Continue the same election as prior year only for insured benefits.Continue same elections as prior year.Be considered to have elected not to participate for upcoming Plan Year. List any Affiliated Employers   Claims for Reimbursement must be filed within (this is the run-out) Number of days following the Plan year  * Number of days following Termination  *   Would you like to know about our referral program to save you additional money? Yes No   List Any Referrals that may be able to use our Services Other Comments:     Agent and Fees Please provide us with your Insurance Agents Name Please provide us with the fees quoted as provided to you by the named agent Setup Fee Annual Compliance Fee you were quoted Monthly Fee per Participant 5500 Fee Security code:   * Do not enter anything in this field:

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