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Vantage Flex, LLC
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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.
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
Corporation
S Corporation
Limited Liability Company
Professional Corporation
Partnership
Government 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 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
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 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 month following requirements
First pay period following requirements
Date 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 year
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Reimbursement Schedule
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Weekly Reimbursement Schedule
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Plan will Reimburse
All Section 213 Expenses
Core Insurance Expenses only
Core Insurance Deductible Expenses only
Core 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
Do not enter anything in this field:
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Please fill this field.
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