1Company2Billing 3Broker/ Agent Contact(s)4Plan(s)5Eligibility 6Funding 7EDI Services8Required Forms/Data9Upload Files 10Client Acknowledgements & Signature COMPANY INFORMATIONDoes Company Offer a Group Health Plan?* Yes No A Traditional FSA Plan Cannot Be Offered If A Group Health Plan Is Not OfferedCompany may proceed if they will be offering a LPFSA (Limited Purpose FSA), Transit and Parking Plans, and/or an HSALegal Company Name* DBA Employer Tax ID Number* Employer EntityCorporationS-CorporationLLCLLPPartnershipEmployer SizeEmployees CoveredPhysical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Contact* First Last Primary Title Primary Email* Enter Email Confirm Email Primary PhoneIs There A Secondary Employer Contact?NoYesSecondary Employer Contact* First Last Secondary Title Secondary Email* Enter Email Confirm Email Secondary PhoneAre There Additional Employer Contacts?NoYesAdditional Employer ContactsContact NameContact Phone#Contact Email Contact NameContact Phone#Contact Email BILLING INFORMATIONBilling information for admin feesAdmin America Services Effective Date mm/dd/yyBroker Billed Broker Billed Broker Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Broker Billing Contact First Last Invoicing of Admin FeesBroker Billing Email Enter Email Confirm Email Invoicing of Admin FeesEmployer Billing Contact Is Same As:* Other - Complete Employer Billing Contact Information Below Primary Employer Contact Secondary Employer Contact Employer Billing Contact* First Last Invoicing of Admin FeesEmployer Billing Email* Enter Email Confirm Email Invoicing of Admin FeesEmployer Billing TelephoneInvoicing of Admin AmericaAre There Additional Employer Billing Contacts?NoYesAdditional Employer Billing ContactsContact NameContact Phone#Contact Email Additional Employer Billing ContactsContact NameContact Phone#Contact Email Method of Payment for Admin Fees* ACH (AA debits the Company's bank account) - Credit Card (Once invoice is emailed to billing contact(s), a link to our online payment system will be available) Company sends AA Payment via ACH. Company mails check to AA each billing cycle *For minimum sized groups we will bill on an annual basis. Otherwise, we will bill monthly. ACH for Admin Fees Options* I authorize the ACH debit of admin fees from same account authorized to fund claim reimbursements. A different account will be used for the ACH debit of admin fees - fill out the AA AACH Authorization Form. Click Here to Access the Admin Fees ACH FormClick Here to Upload Completed ACH Form for Admin Fees BROKER / AGENT CONTACT INFORMATIONAgent/BrokerYesN/AAgent Company* Agency Tax ID Number Agent Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Broker/Agent Name First Last Broker/Agent Email Account Rep(s)*First and Last NameEmail AddressPhone Number PLAN INFORMATIONRegular Plan Year*Plan Year Begin Date (MM/DD)Plan Year End Date (MM/DD) Regular 12 month plan yearIs this a Short Plan Year?*NoYesless than 12 monthsShort Plan YearShort Plan Year Begin Date (MM/DD)Short Plan Year End Date (MM/DD/YY) Is this a Mid-Year Takeover of a Current Plan?NoYesName of Prior TPA Vendor Prior Administrator Final Processing Date: Accounts Offered* Select All HSA (Health Savings Account) Traditional Healthcare FSA Limited Purpose FSA Dependent (Child) Care FSA Qualified Parking Expenses Transit Parking Expenses Accounts Offered* Select All HSA (Health Savings Account) Limited Purpose FSA Dependent (Child) Care FSA Qualified Parking Expenses Transit Parking Expenses ERISA Plan Number 520 (default) ERISA Plan Number should be a 3 digit number between 501 - 520.Medical FSA Annual Election* Max Allowed by IRS Other For Plan Years beginning in 2023, the Federal Max is $3,050 for a full 12 month plan year. Medical FSA other election amount:*Dependent Care FSA Annual Election:* Max Allowed by IRS Other For Plan Years beginning in 2022, the Federal Max is $2,500 Individual or $5,000 per family unit per calendar year. Dependent Care FSA other election amount:*Does the employer contribute money towards the FSA?NoYesExplain Contribution Amount and Any Stipulations in Box Provided Below:*Optional Medical FSA Features* Federal Rollover Max ($610) Participants have 75 days after the plan year ends to incur expenses No Optional Features Allowed Optional Dependent Care FSA Features Participants have 75 days after the plan year ends to incur expenses Other (less than 75 days) 0 Days Number*Please enter a number from 1 to 74.Earliest Effective Date of Participant HSA Accounts Will an HSA Qualified High Deductible Group Health Plan be Available as of the Effective Date of the HSA?*YesNoName of Medical Insurance Carrier:* Does the employer contribute money towards the HSA?NoYesIf "Yes", How Much Per Employee Per Year. Please Explain:HSA Transfers: Do Any of the Employees Have Current HSA Accounts? No Yes If "Yes", Would You Like Assistance With Trustee to Trustee Rollovers? No Yes Is an HRA currently offered?NoYesWill it pay out before FSA funds?NoYesInsurance Premiums Payroll Deducted on a Pre-Tax Basis Select All Group Health Insurance Group Dental Insurance Group Vision Insurance Health Savings Account Cancer/Dread Disease Insurance Critical Illness Hospital Indemnity STD or LTD Disability (typically not pre-taxed) Life Insurance (typically not pre-taxed) Other Define "Other" Does Company Currently Offer an FSA Plan? No Yes Does Admin America Currently Administer Your Company's FSA Plan? No Yes Does the Company Have a Current POP (Premium Only Plan) in Place? No Yes Admin America will prepare your POP Documents for a $400 fee. Click Here to Access the POP Online Application; OR send us a Sales Inquiry Sales Queries Do you have questions about Admin America's POP Document Services or any of our other Compliance and Administration Services? Send an email and we'll get in touch shortly, our dedicated sales team is ready to help. Your Name (required) Your Email (required) Subject Your Message Δ Δ Tell us about any additional information that we need to know about the plan here: ELIGIBILITY INFORMATIONEligibility DateOtherDate of hire (no service required)30 days after hire60 days after hire90 days after hire*eligibility date cannot be less than the medical insurance eligibility date.Enter Other Eligibility Date: Entry DateOtherSame day1st day1st pay period1st of month1st of new plan yearEnter Other Entry Date: Employees to be Excluded from the Plan(s)*OtherPart-time Employees (<30 hrs weekly)No Employees are to be ExcludedEnter Employees to be Excluded from the Plan(s)*Participants who terminate employment may be reimbursed from the Medical FSA:*Only for expenses termed prior to termination (recommended)Last payroll deduction dateParticipants who terminate employment may be reimbursed from the Dependent Care FSA:*For expenses incurred during the remainder of the Plan Year (recommended)Only for expenses incurred prior to terminationWithin # of Days# of Days (Terminated participants have to be reimbursed for Dep Care FSA expenses)Number of Days Participants Have to File Claims After the Plan Year Ends.*90 Days0 Days30 Days60 Days120 DaysOtheremployer can allow participants a certain number of days to submit claims for reimbursement which were incurred during the plan year. Number of Days to File Claims* FUNDING INFORMATIONNumber of Salary Deductions Taken:* Weekly (52) Biweekly (24) Biweekly (26) Semimonthly (24) Monthly (12) Based on Class Define Number of Salary Deductions Taken for Each Class of Employees:Define each class.1st Salary Deduction Date(s):*Define each class.Frequency of Claim Reimbursements (FSA/TRP)* Weekly (52) - Recommended Bi-Weekly (24) Bi-Weekly (26) Semimonthly (24) Monthly (12) In relation to how often Admin America processes claims for reimbursement. Check & Bank Account Admin Options*Admin America Acct - Checks Created & Signed by Admin America (Recommended)Co Accnt - Checks Digitally Signed by the CompanyIn relation to out of pocket claims for reimbursement. Not debit card transactions. Direct Deposit Option*YesNoAllow the direct deposit of claims reimbursements into the participants personal bank account in lieu of a check. Debit Card Option*YesNo EDI ServicesAdditional fees may apply. Was There A Prior Year Medical FSA Plan With A Rollover Provision? No Yes If, "yes" we will need a rollover report once the run out period with the prior vendor has been finalized.Rollover Amount* Provide Rollover amount defined by the previous year's plan documents. i.e.; $550 (2021 federal max)Is this An Employee Navigator Integration?* No Yes Is the Company Requesting for Admin America to Integrate with Company's Current EDI Vendor/Payroll?* Yes No Admin America charges a one time $250 SetUp Fee for this service.Accept EDI Feed Pricing* Decline EDI Option Eligibility Files - $250 Consent to EDI Fee* I agree to the EDI FeesI consent to the $250 fee for Admin America to begin the integration process with the company's EDI vendor. EDI Vendor Name EDI Vendor Contact will need to send an email to edi@adminamerica.com to begin the integration process. REQUIRED FORMS & DATAPlease upload all required bank forms and elections. Click Here to Access the Bancorp Bank Debit Card Funding Authorization FormClick Here to Access the AA ACH Authorization FormClick Here to Access the AA ACH Authorization FormClick Here to Access the Signature Authorization FormClick Here to Access the FSA Enrollment CensusClick Here to Access the FSA Enrollment Census w ER ContributionsClick Here to Access the FSA Takeover Enrollment CensusClick Here to Access the HSA HDHP Enrollment CensusClick Here to Access the TRP8 Participant Election Form Secure UploadsClick Here to Upload the FSA Bank Forms and Enrollment Census CLIENT SIGNATURE Please complete the form carefully and submit accurate final balance reports. Any changes that cause Admin America Inc. to audit the account and reprocess claims will result in a $300.00 auditing fee.By entering your name below you are electronically signing this form. I understand the reprocessing fee stating above. The information I have supplied herein is accurate and should be used by Admin America Inc. as of the date in which Admin America takes over. Your Name* Email* Date* MM slash DD slash YYYY CAPTCHA Δ
