Company Name  * EIN  * Address  * City  * State  * Zip Code  * Comments Contact Name  * Phone Number  * Email Address  * Fax Number PHI Officer  * Principal Office Location (State)  * Employer Entity CorporationS CorporationLimited Liability CompanyProfessional CorporationPartnershipGovernment 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 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 InsuranceSalaried Employees OnlyHourly Employees OnlyAll employees except those checked below Union Employees Leased Employees Part-time employees (see below) Full-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 month following requirementsFirst pay period following requirementsDate conditions for eligibliity are met Employer Contribution Levels Enter each contribution level with a description of that level (Employee only - $500) Level 1 Level 2 Level 3 Level 4 Contributions will be made Annually at the beginning of the plan yearWeeklyBi-WeeklySemi-MonthlyMonthly Reimbursement Schedule WeeklyBi-WeeklySemi-MonthlyMonthly Weekly Reimbursement Schedule MondayTuesdayWednesdayThursdayFridaySaturdaySunday Plan will Reimburse All Section 213 ExpensesCore Insurance Expenses onlyCore Insurance Deductible Expenses onlyCore Insurance Deductible Expenses only above $1000 deductible for single and $2000 deductible for family (HSA Eligibility)All Section 213 Expenses above $1000 deductible for single and $2000 deductible for family (HSA Eligibility)Dental and Vision Expenses only Allow Over-The-Counter Drugs (OTC) to be reimbursed? Yes No Plan will Reimburse at what percent (%) of each claim? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Roll Option No funds will Roll Roll all funds Roll a percentage of the funds Roll a percentage of the funds with a maximum amount of roll Percentage of Roll Maximum amount of Roll Establish a Retirement Class? No Yes Retirement Class will include a spend down option No Yes Retirement Class will receive a contribution? No Yes Amount of Retirement Class Contribution Terminated Employees shall Forfeit all funds following the run-out Be allowed to spend down the funds   Claims for Reimbursement must be filed within (this is the run-out) Number of days following the plan year end 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 Monthly Fee per Participant 5500 Fee Security code:   * Do not enter anything in this field:

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