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Install an HRA 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.

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Family Medical Leave Act
Ordering Rule
Plan Information
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The first year is
Employer Contribution Levels
Enter each contribution level with a description of that level (Employee only - $500)
Allow Over-The-Counter Drugs (OTC) to be reimbursed?
Plan will Reimburse at what percent (%) of each claim?
Roll Option
Establish a Retirement Class?
Retirement Class will include a spend down option
Retirement Class will receive a contribution?
Terminated Employees shall
 
Claims for Reimbursement must be filed within (this is the run-out)
 
Would you like to know about our referral program to save you additional money?
 
 
Agent and Fees
Please provide us with the fees quoted as provided to you by the named agent.
* indicates a required field
Please fill this field.
FSA Eligible Expenses and Items