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Vantage Flex, LLC
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Install a POP Plan
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Install a Flex Plan
If you have questions while completing this form or would like more information, please feel free to contact us at (800)871-9011. If it is after business hours, please leave your name and contact information and we will return your call as soon as possible.
Company Name
*
EIN
*
Address
*
City
*
State
*
Zip Code
*
Contact Name
*
Phone Number
*
Email Address
Fax Number
PHI Officer
*
Principal Office Location (State)
*
Employer Entity
Corporation
S Corporation
Limited Liability Company
Professional Corporation
Partnership
Governmental Entity
Church
Non-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 report
Vantage Flex
Electronic Fund Transfer
Employer 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 Only
Hourly Employees Only
All 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 Plan
30 days following employment
60 days following employment
90 days following employment
180 days following employment
Entry Date
Same as Employers Group Medical plan
First day of the month following requirements.
First Pay period following Requirements
Date conditions for eligibility are met
Contribution to be made by
Salary reduction ONLY
Employer contributions ONLY
Both 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
Do not enter anything in this field:
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indicates a required field
Please fill this field.
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