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Admin America, Inc.

Alpharetta, GA 30005

770-992-5959 or 1-800-366-2961

info@adminamerica.com

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Home
About Us
LOGIN
Services
- FSA
- HRA
- COBRA
- HSA
- POP
- ERISA Wrap
- Form 5500
- ACA Employer Reporting
Resources
Contact Us
Payment Center
Open Enrollment Portal
Blog

1 EMPLOYER INFORMATION

2 PLAN INFORMATION

3 FEDERAL NOTICES INFORMATION

4 WELLNESS / VARIABLE HOUR EES INFORMATION

5 HEALTH PLAN(S) DESCRIPTION

6 RETIREE HEALTH PLAN(S) DESCRIPTION

7 DENTAL PLAN(S) DESCRIPTION

8 VISION PLAN(S) DESCRIPTION

9 LIFE/AD&D PLAN(S) DESCRIPTION

10 LTD PLAN(S) DESCRIPTION

11 STD PLAN(S) DESCRIPTION

12 FSA PLAN DESCRIPTION

13 HRA PLAN DESCRIPTION

14 EAP PLAN DESCRIPTION

15 WORKSITE BENEFIT PLAN(S) DESCRIPTION

16 BROKER INFORMATION

17 DELIVERY AND BILLING INSTRUCTIONS

18 APPROVAL & SIGNATURE

EMPLOYER INFORMATION
Employer's Legal Name
Employer Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employer Phone Number
Federal EIN
Type Of Business
- C Corp
- S Corp
- LLC
- Government
Employer Contact Name
First Last
Employer Contact Title
Employer Contact Email
Enter Email Confirm Email
Employer Contact Phone
Employer Logo File
Drop files here or
Please upload a logo file (JPEG, BMP, PNG)

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PLAN INFORMATION
Name Of Plan
If DBA applies, please include DBA Name.
Employer Type
- Single Employer Plan
- Multiple Employer Group
- Controlled Group
Affiliates Information
Company Name Company Address Company Phone# Company FEIN#

List Subsidiary Information
Plan Number (5500)
The Plan number for ERISA Form 5500 purposes, e.g., 501, 502, 503, etc. (Note—each ERISA Plan should be assigned a unique number that is not used more than once.)
Number Of Employee Participants
Total Number Of Employees
Exclude The Following Employee Classes (This field is required)
- Select All
- None
- 1099/Sub Contractors
- Hourly Employees
- Leased Employees
- Non-Resident Alines
- Salaried Employees
- Union
- Other
This pertains to the eligibility of the Plan itself and not the underlying benefits. Select the employee classes that will NOT be eligible for benefits under the Plan.
Other Employee Class Excluded
Plan Year Begins
MM
DD
YYYY
Plan Year Ends
MM
DD
YYYY
Is This A Restatement To A Previous Wrap Document?
- Yes
- No
Last Wrap Date
Date Format: MM slash DD slash YYYY
Any Other Named Fiduciary (Trustee)
- Yes
- No
ERISA § 11 02( a). The trustee or trustees must either be named in the trust instrument or in the plan instrument or appointed by a person who is a named fiduciary. ... This is unremarkable given that the trustee is the person responsible for holding and managing the plan's assets.
Named Fiduciary (Trustee)
Phone For Named Fiduciary (Trustee)
Address For Named Fiduciary (Trustee)*
Street Address Address Line 2 City State ZIP Code
Is The Plan Sponsor (Company) Also The Agent For Service Of Legal Process?
- Yes
- No
The person or company designated to accept service of process on behalf of the company.
Agent For Service Of Legal Process
The person or company designated to accept service of process on behalf of the company.
Phone For Agent For Service Of Legal Process
Address For Agent Of Service For Legal Process
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is the Plan Sponsor (Company) also the COBRA Administrator?
- Yes
- No
COBRA Administrator Name
COBRA Administrator Phone#
COBRA Administrator Address
Same as previous

Street Address Address Line 2 City State ZIP Code
Does The Plan Offer Any Self-Funded or Partially Funded Benefits?
Does The Plan Offer A Healthcare Flexible Spending (FSA) Account?
Does The Plan Offer A Health Reimbursement (HRA) Account?
Privacy Officer's Title
Privacy Officer's Phone#
Privacy Notice Effective Date
Date Format: MM slash DD slash YYYY

The effective date of the notice may not be earlier than the date on which the Notice is printed or otherwise published.
Website

Website address in which the participant can obtain a copy of the Privacy Notice.

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FEDERAL NOTICES INFORMATION
Did The Company Have PRIOR Year Health Insurance?
- Yes
- No
PRIOR Year Health Insurance Plan Year Begin Date
MM
DD
YYYY
PRIOR Year Health Insurance Plan Year End Date
MM
DD
YYYY
PRIOR Health Insurance Plan Year Information
Carrier Plan Name CMS Status (Credible/Non-Credible)
Check If Current Health Plan Information Is Same As Prior
- Same As Prior Plan Year
Current Health Insurance Plan Year Begin Date
MM
DD
YYYY
Current Health Insurance Plan Year End Date
MM
DD
YYYY
CURRENT Health Insurance Plan Year Information
Carrier Plan Name CMS Status (Credible/Non-Credible)
Is A PCP Required For Any Of The Health Plans?
- Yes
- No
Some health plans may require a participant to select a primary care physician (PCP).
Name Of Health Plan(s) Requiring A PCP Election
Is A Separate Retiree Medical Plan Offered?
- Yes
- No
May Employee Retain RX Coverage When Eligible For Medicare?
- Yes
- No
Will Rx Coverage Coordinate With Medicare?
- Yes
- No
Name Of Lowest-Cost, Passing Health Plan
"Passing Plan" is a plan that meets PPACA standards, if applicable. If multiple employee classes/health plans, provide name of lowest cost passing plan for each EE class.
Cost To Employee Per Year For The Lowest -Cost, Passing Health Plan
Please provide the cost to the employee (employee contribution only) per year; e.g. $50.00 monthly employee contribution X 12 (months) = $600.00 If multiple employee classes/health plans, provide lowest cost for each EE class.
Are There Any Employees That Are Not Offered A Health Plan?
- Yes
- No
Are There Any Employees That Are Not Offered A Health Plan? e.g. Part-Time Employees
Does The Company Directly Or Indirectly Receive HHS Funding?
- Yes
- No
Covered entities which have a health program or activity, part of which receives funding from HHS (such as hospitals that accept Medicare or doctors who accept Medicaid), are required to post notices of nondiscrimination and taglines that alert individuals with limited English proficiency to the availability of language assistance services. Section 1557 of the Affordable Care Act (ACA), prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in any health program or activity that receives federal financial assistance.
Does The Company Recognize Legal Separation As A Qualifying HHS Funding Life Event?
- Yes
- No
Does The Company Offer An HSA?
- Yes
- No
Does The Company Contribute To The HSA?
- Yes
- No
HSA TAX STATUS OF EMPLOYEE CONTRIBUTIONS
HSA PLAN CLAIMS CONTACT
HSA PLAN CLAIMS CONTACT NAME HSA PLAN CLAIMS CONTACT ADDRESS HSA PLAN CLAIMS CONTACT PHONE#

Name of HSA Bank

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WELLNESS INFORMATION
Does Your Company Offer A Wellness Program That Collects Employee Health Information?
- Yes
- No
Wellness programs that allow the company to provide limited incentives that make disability-related inquiries or require medical examinations are considered programs that collect employee health information. Incentives may be financial or in-kind (e.g., time-off awards, prizes, and other items of value). This rule does not apply to wellness programs that do not obtain medical information but simply require employees to engage in a certain activity (such as attending a nutrition or weight loss class or walking a certain amount every week) in order to earn an incentive.
Name Of Wellness Program
Is Wellness Program Offered To All Employees And Their Dependents?
- Yes
- No
Does Wellness Program Ask For Completion Of A Voluntary Health Assessment Or Bio-metric Screening?
- Yes
- No
What Discretionary Incentives Does A Participant Receive?
In Example: Incentives such as gift cards and/or premium incentives. No such rewards are considered to be outcome based.
Are There Additional Incentives Provided For Participants Who Participate In Other Health-Related Activities Or Achieve Certain Health Outcomes?
- Yes
- No
Specify Health Related Activities Or Achievement Of Certain Health Outcomes.
Are Other Services Provided As A Result From Health Assessment And/or Bio-metric Screening?
- Yes
- No
Indicate Other Services That May Be Offered.
The information from a health assessment and/or the results from your bio-metric screening will be used to provide participants with information to help them understand their current health and potential risks, and may also be used to offer them services through the wellness program.
Who Will Receive Personally Identifiable Health Information In Order to Provide Services Under The Wellness Program?
Indicate who will receive information such as "a registered nurse," "a doctor," or "a health coach"
VARIABLE HOUR EMPLOYEE INFORMATION
Do You Have Variable Hour Employees?
- Yes
- No
The ACA defines an employee as variable hour if, based on the facts and circumstances on the employee’s start date, an employer cannot determine whether the employee is reasonably expected to work an average of at least 30 hours per week during the initial measurement period because the employee’s hours are variable or uncertain.
Variable Hours Additional Notes
Will You Be Using The IRS Look-Back Measurement Method To Determine Employee Status?
- Yes
- No
NEW Employees: Measurement Period
(Initial Measurement Period may not exceed 13 months)
NEW Employees: Measurement Period Begins
In Example: 1st of Month Following Date of Hire
NEW Employees: Administrative Period
1-90 days (Initial Measurement Period and Administrative Period may not exceed 13 months)
NEW Employees: When coverage becomes effective
In Example: 1st of Month Following End of Administrative Period.
NEW Employees: Stability Period
In Example: 12 Months
ONGOING Employees: Measurement Period
In Example: 12 Months
ONGOING Employees: Measurement Period Begins
3-12 months
ONGOING Employees: Administrative Period
1-90 days
ONGOING Employees: Coverage Becomes Effective
ONGOING Employees: Stability Period
6-12 months

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COMPONENT BENEFITS PLAN(S) DESCRIPTION SECTION
Instructions for the ‘Benefits’ Section:  *On the Following pages verbiage should match contracts & be reflected in the Client’s Admin practices. Ensure you have included all benefits required to be disclosed.
GROUP HEALTH PLAN(S) DESCRIPTION
HEALTH PLAN(S)
Name of Component Benefit Plan(s)

Provide name of the component benefit plan(s); e.g. Cigna Group Health Plan.
HEALTH PLAN(S) EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
HEALTH PLAN CLAIMS PAID BY
Claims paid by is the entity that funds the claims; e.g. fully insured plan would be funded by Insurer.
HEALTH PLAN(S) (CLAIMS PAYMENT) SERVICES PROVIDED BY
"Services Provided" is the entity that administers claims.
HEALTH PLAN(S) SOURCE OF PLAN CONTRIBUTIONS
"Source of Plan Contributions" refers to contributions of insurance premium.
HEALTH PLAN(S) TAX STATUS OF EMPLOYEE CONTRIBUTIONS
HEALTH PLAN(S) ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
HEALTH PLAN(S) WHEN EMPLOYEE PARTICIPATION BEGINS
HEALTH PLAN(S) WHEN EMPLOYEE PARTICIPATION ENDS
HEALTH PLAN(S) INELIGIBLE EMPLOYEES
Example: Employees who are not considered Full-Time or Seasonal.
HEALTH PLAN(S) ELIGIBLE DEPENDENTS
HEALTH PLAN CLAIMS CONTACT
HEALTH PLAN CLAIMS CONTACT NAME; E.G. UHC RIVER VALLEY HEALTH PLAN CLAIMS MAILING ADDRESS HEALTH PLAN CLAIMS PHONE#

Example: Cigna Global Health Options
Upload Medical SBCs
Drop files here or

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RETIREE HEALTH PLAN(S) DESCRIPTION
RETIREE HEALTH PLAN
Name of Component Benefit Plan(s)

Provide name of the component retiree benefit plan.
RETIREE HEALTH PLAN CLAIMS PAID BY
Claims paid by is the entity that funds the claims; e.g. fully insured plan would be funded by Insurer.
RETIREE PLAN(S) (CLAIMS PAYMENT) SERVICES PROVIDED BY
"Services Provided" is the entity that administers claims.
RETIREE PLAN(S) SOURCE OF PLAN CONTRIBUTIONS
"Source of Plan Contributions" refers to contributions of insurance premium.
RETIREE PLAN(S) ELIGIBLE DEPENDENTS
RETIREE HEALTH PLAN CLAIMS CONTACT
RETIREE HEALTH PLAN CLAIMS CONTACT NAME; E.G. UHC RIVER VALLEY RETIREE HEALTH PLAN CLAIMS MAILING ADDRESS RETIREE HEALTH PLAN CLAIMS PHONE#

Example: Cigna Global Health Options

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IS GROUP DENTAL INSURANCE OFFERED TO EMPLOYEES?
- Yes
- No
DENTAL PLAN(S) DESCRIPTION
DENTAL PLAN(S)
Name of Component Benefit Plan(s)

Provide name of the component dental benefit plan.
DENTAL PLAN(S) EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
DENTAL PLAN(S) BENEFITS FUNDED BY
Benefits funded by is the entity that funds the claims; e.g. fully insured plan would be funded by Insurer.
DENTAL PLAN(S) (CLAIMS PAYMENT) SERVICES PROVIDED BY
"Services Provided" is the entity that administers claims.
DENTAL PLAN(S) SOURCE OF PLAN CONTRIBUTIONS
"Source of Plan Contributions" refers to contributions of insurance premium.
DENTAL PLAN(S) TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If Dental Plan Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
DENTAL PLAN(S) ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If Dental Plan Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
DENTAL PLAN(S) WHEN EMPLOYEE PARTICIPATION BEGINS
Check If Dental Plan Employee Participation End Date Is The Same As The Health Plan
- Same As Health Plan
DENTAL PLAN(S) WHEN EMPLOYEE PARTICIPATION ENDS
Check If Dental Ineligible Employee Defintion Is The Same As The Health Plan
- Same As Health Plan
DENTAL PLAN(S) INELIGIBLE EMPLOYEES
Example: Employees who are not considered Full-Time or Seasonal.
DENTAL PLAN(S) ELIGIBLE DEPENDENTS
DENTAL PLAN(S) CLAIMS CONTACT
DENTAL PLAN CLAIMS CONTACT NAME DENTAL PLAN CLAIMS MAILING ADDRESS DENTAL PLAN CLAIMS PHONE#

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IS VISION INSURANCE OFFERED TO EMPLOYEES?
- Yes
- No
VISION PLAN(S) DESCRIPTION
VISION PLAN(S)
Name of Component Benefit Plan(s)

Provide name of the component vision benefit plan.
VISION PLAN(S) EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
VISION PLAN(S) BENEFITS FUNDED BY
Benefits funded by is the entity that funds the claims; e.g. fully insured plan would be funded by Insurer.
VISION PLAN(S) (CLAIMS PAYMENT) SERVICES PROVIDED BY
"Services Provided" is the entity that administers claims.
VISON PLAN(S) SOURCE OF PLAN CONTRIBUTIONS
"Source of Plan Contributions" refers to contributions of insurance premium.
VISION PLAN(S) TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If Vison Plan Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
VISION PLAN(S) ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If Vision Plan Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
VISION PLAN(S) WHEN EMPLOYEE PARTICIPATION BEGINS
Check If Vision Plan Employee Participation End Date Is The Same As The Health Plan
- Same As Health Plan
VISION PLAN(S) WHEN EMPLOYEE PARTICIPATION ENDS
Check If Vision Plan Ineligible Employee Defintion Is The Same As The Health Plan
- Same As Health Plan
VISION PLAN(S) INELIGIBLE EMPLOYEES
Example: Employees who are not considered Full-Time or Seasonal.
VISION PLAN(S) ELIGIBLE DEPENDENTS
VISION PLAN(S) CLAIMS CONTACT
VISION PLAN CLAIMS CONTACT NAME VISION PLAN CLAIMS MAILING ADDRESS VISION PLAN CLAIMS PHONE#

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IS BASE LIFE INSURANCE OFFERED TO EMPLOYEES?
- Yes
- No
Source of Plan Contributions Is 100% Employer Paid.
IS BASE AD&D INSURANCE OFFERED TO EMPLOYEES?
- Yes
- No
Source of Plan Contributions Is 100% Employer Paid.
IS VOLUNTARY LIFE INSURANCE OFFERED TO EMPLOYEES?
- Yes
- No
Source of Plan Contributions Is 100% Employee Paid.
IS VOLUNTARY AD&D INSURANCE OFFERED TO EMPLOYEES?
- Yes
- No
Source of Plan Contributions Is 100% Employee Paid.
LIFE (AD&D) PLAN(S) DESCRIPTION
LIFE (AD&D) PLAN(S)
Name of Component Benefit Plan(s)

Provide name of the component Life & AD&D benefit plan.
BASE LIFE (AD&D) / VOLUNTARY LIFE (AD&D) PLAN(S) EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
Are Dependents Eligible For The Base Life (AD&D)
LIFE (AD&D) PLAN(S) (CLAIMS PAYMENT) SERVICES PROVIDED BY
"Services Provided" is the entity that administers claims.
LIFE (AD&D) PLAN(S) TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If Life/AD&D Plan Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
LIFE (AD&D) PLAN(S) ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
LIFE (AD&D) PLAN(S) WHEN EMPLOYEE PARTICIPATION BEGINS
LIFE (AD&D) PLAN(S) WHEN EMPLOYEE PARTICIPATION ENDS
Life & AD&D benefits typically end as of date employee becomes ineligible.
LIFE (AD&D) PLAN(S) INELIGIBLE EMPLOYEES
Example: Employees who are not considered Full-Time or Seasonal.

BASE LIFE (AD&D) / VOLUNTARY LIFE (AD&D) PLAN(S) CLAIMS CONTACT

BASE LIFE (AD&D) PLAN CLAIMS CONTACT NAME	BASE LIFE (AD&D) PLAN CLAIMS MAILING ADDRESS	BASE LIFE (AD&D) PLAN CLAIMS PHONE#	VOLUNTARY LIFE (AD&D) PLAN CLAIMS CONTACT NAME	VOLUNTARY LIFE (AD&D) PLAN CLAIMS MAILING ADDRESS	VOLUNTARY LIFE (AD&D) PLAN CLAIMS PHONE#

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IS LONG TERM DISABILITY (LTD) INSURANCE OFFERED TO EMPLOYEES?
- Yes
- No
LTD PLAN(S) DESCRIPTION
LTD PLAN(S)
Name of Component Benefit Plan(s)

Provide name of the component LTD benefit plan.
LTD PLAN(S) EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
LTD PLAN(S) (CLAIMS PAYMENT) SERVICES PROVIDED BY
"Services Provided" is the entity that administers claims.
LTD PLAN(S) SOURCE OF PLAN CONTRIBUTIONS
"Source of Plan Contributions" refers to contributions of insurance premium.
LTD PLAN(S) TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If LTD Plan Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
LTD PLAN(S) ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If LTD Plan Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
LTD PLAN(S) WHEN EMPLOYEE PARTICIPATION BEGINS
Check if LTD Plan Employee Participation End Date Is The Same As The Health Plan
- Same As Health Plan
LTD PLAN(S) WHEN EMPLOYEE PARTICIPATION ENDS
LTD benefits typically end as of date employee becomes ineligible.
Check If LTD Plan Ineligible Employee Definition Is The Same As The Health Plan
- Same As Health Plan
LTD PLAN(S) INELIGIBLE EMPLOYEES
Example: Employees who are not considered Full-Time or Seasonal.
LTD PLAN(S) CLAIMS CONTACT
LTD PLAN CLAIMS CONTACT NAME LTD PLAN CLAIMS CONTACT ADDRESS LTD PLAN CLAIMS CONTACT PHONE#

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IS SHORT TERM DISABILITY (STD) INSURANCE OFFERED TO EMPLOYEES?
- Yes
- No
STD PLAN(S) DESCRIPTION
STD PLAN(S)
Name of Component Benefit Plan(s)

Provide name of the component STD benefit plan.
STD PLAN(S) EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
STD PLAN(S) (CLAIMS PAYMENT) SERVICES PROVIDED BY
"Services Provided" is the entity that administers claims.
STD PLAN(S) SOURCE OF PLAN CONTRIBUTIONS
"Source of Plan Contributions" refers to contributions of insurance premium.
STD PLAN(S) TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If STD Plan Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
STD PLAN(S) ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If STD Plan Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
STD PLAN(S) WHEN EMPLOYEE PARTICIPATION BEGINS
Check If STD Plan Employee Participatin End Date Is The Same As The Health Plan
- Same As Health Plan
STD PLAN(S) WHEN EMPLOYEE PARTICIPATION ENDS
STD benefits typically end as of date employee becomes ineligible.
Check If STD Plan Ineligible Employee Definition Is The Same As The Health Plan
- Same As Health Plan
STD PLAN(S) INELIGIBLE EMPLOYEES
Example: Employees who are not considered Full-Time or Seasonal.
STD PLAN(S) CLAIMS CONTACT
STD PLAN CLAIMS CONTACT NAME STD PLAN CLAIMS CONTACT ADDRESS STD PLAN CLAIMS CONTACT PHONE#

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IS A HEALTHCARE FLEXIBLE SPENDING (FSA) PLAN OFFERED TO EMPLOYEES?
- Yes
- No
IS A DEPENDENT CARE FLEXIBLE SPENDING (FSA) PLAN OFFERED TO EMPLOYEES?
- Yes
- No
FSA PLAN(S) DESCRIPTION
FSA PLAN(S)
Name of Component Benefit Plan(s)

Provide name of the component Flexible Spending benefit plan.
Check If FSA Plan Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
FSA PLAN(S) ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
DOES THE EMPLOYER CONTRIBUTE TO THE FSA
Does the employer contribute "seed money" into the participant's FSA account.
Check If FSA Plan Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
FSA PLAN(S) WHEN EMPLOYEE PARTICIPATION BEGINS
HEALTHCARE FSA PLAN WHEN EMPLOYEE PARTICIPATION ENDS
Healthcare FSA benefits typically end as of date employee becomes ineligible.
DEPENDENT CARE FSA PLAN WHEN EMPLOYEE PARTICIPATION ENDS
Dependent Care FSA benefits typically end as of end of the plan year.
Check If FSA Plan(s) Ineligible Employee Defintion Is The Same As The Health Plan
- Same As Health Plan
FSA PLAN(S) INELIGIBLE EMPLOYEES
Example: Employees who are not considered Full-Time or Seasonal.
FSA PLAN(S) CLAIMS CONTACT
FSA PLAN CLAIMS CONTACT NAME FSA PLAN CLAIMS CONTACT ADDRESS FSA PLAN CLAIMS CONTACT PHONE#

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IS A HEALTH REIMBURSEMENT ACCOUNT (HRA) PLAN OFFERED TO EMPLOYEES?
- Yes
- No
HRA PLAN(S) DESCRIPTION
HRA ACCOUNT
Name of Component Benefit Plan(s)

Provide name of the HRA Plan
HRA PLAN(S) ELIGIBLE EMPLOYEE DESCRIBED
In Example: Employees Participating In The UHC PPO Plan.
Are Dependents Eligible For The Health Reimbursement Account (HRA)
HRA CLAIMS CONTACT
HRA PLAN CLAIMS CONTACT NAME HRA PLAN CLAIMS CONTACT ADDRESS HRA PLAN CLAIMS CONTACT PHONE#

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IS A COBRA ELIGIBLE EMPLOYEE ASSISTANCE PROGRAM (EAP) OFFERED TO EMPLOYEES?
- Yes
- No
EAP PLAN DESCRIPTION
EAP PLAN
Name of Component Benefit Plan(s)

Provide name of the EAP Plan.
EAP PLAN WHEN EMPLOYEE PARTICIPATION BEGINS
EAP PLAN INELIGIBLE EMPLOYEES
Example: Employees who are not considered Full-Time or Seasonal.
EAP PLAN CLAIMS CONTACT
EAP PLAN CLAIMS CONTACT NAME EAP PLAN CLAIMS CONTACT ADDRESS EAP PLAN CLAIMS CONTACT PHONE#
Additional Comments on COBRA Eligible EAP

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WORKSITE BENEFITS
Worksite Benefits are voluntary individual policy arrangements that are issued to employees who sign up and pay for coverage. *Note these type of plans may also be subject to ERISA based on the employer's involvement-and, if it provides health benefits. Examples of such arrangements are: •Accident •Cancer •Critical Illness •Hospital Indemnity •Short-Term Disability •Long-Term Disability •Life •ID Theft Protection •Prepaid Legal
ARE WORKSITE BENEFITS OFFERED?
- Yes
- No
#1 Name of Worksite Benefit Offered
#1 WORKSITE BENEFIT OFFERED EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
#1 WORKSITE BENEFIT OFFERED EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
#1 WORKSITE BENEFIT TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If #1 Worksite Benefit Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
#1 WORKSITE BENEFIT PLAN ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If #1 Worksite Benefit Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
#1 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION BEGINS
Check If #1 Worksite Benefit Employee Participatin End Date Is The Same As The Health Plan
- Same As Health Plan
#1 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION ENDS
Worksite benefits typically end as of date employee becomes ineligible.
#1 WORKSITE BENEFIT CLAIMS CONTACT
#1 WORKSITE BENEFIT CLAIMS CONTACT NAME #1 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS #1 WORKSITE BENEFIT CLAIMS CONTACT PHONE#
Check if #2 Worksite Benefit is offered
- #2 Worksite Benefit Offered
#2 Name of Worksite Benefit Offered
#2 WORKSITE BENEFIT OFFERED EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
#2 WORKSITE BENEFIT TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If #2 Worksite Benefit Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
#2 WORKSITE BENEFIT PLAN ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If #2 Worksite Benefit Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
#2 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION BEGINS
Check If #2 Worksite Benefit Employee Participatin End Date Is The Same As The Health Plan
- Same As Health Plan
#2 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION ENDS
Worksite benefits typically end as of date employee becomes ineligible.
#2 WORKSITE BENEFIT CLAIMS CONTACT
#2 WORKSITE BENEFIT CLAIMS CONTACT NAME #2 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS #2 WORKSITE BENEFIT CLAIMS CONTACT PHONE#

*Claims Address and Phone # are required.
Check if #3 Worksite Benefit is offered
- #3 Worksite Benefit Offered
#3 Name of Worksite Benefit Offered
#3 WORKSITE BENEFIT OFFERED EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
#3 WORKSITE BENEFIT TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If #3 Worksite Benefit Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
#3 WORKSITE BENEFIT PLAN ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If #3 Worksite Benefit Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
#3 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION BEGINS
Check If #3 Worksite Benefit Employee Participatin End Date Is The Same As The Health Plan
- Same As Health Plan
#3 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION ENDS
Worksite benefits typically end as of date employee becomes ineligible.
#3 WORKSITE BENEFIT CLAIMS CONTACT
#3 WORKSITE BENEFIT CLAIMS CONTACT NAME #3 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS #3 WORKSITE BENEFIT CLAIMS CONTACT PHONE#

*Claims Address and Phone # are required.
Check if #4 Worksite Benefit is offered
- #4 Worksite Benefit Offered
#4 Name of Worksite Benefit Offered
#4 WORKSITE BENEFIT OFFERED EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
#4 WORKSITE BENEFIT TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If #4 Worksite Benefit Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
#4 WORKSITE BENEFIT PLAN ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If #4 Worksite Benefit Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
#4 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION BEGINS
Check If #4 Worksite Benefit Employee Participatin End Date Is The Same As The Health Plan
- Same As Health Plan
#4 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION ENDS
Worksite benefits typically end as of date employee becomes ineligible.
#4 WORKSITE BENEFIT CLAIMS CONTACT
#4 WORKSITE BENEFIT CLAIMS CONTACT NAME #4 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS #4 WORKSITE BENEFIT CLAIMS CONTACT PHONE#

*Claims Address and Phone # are required.
Check if #5 Worksite Benefit is offered
- #5 Worksite Benefit Offered
#5 WORKSITE BENEFIT OFFERED EE CLASSES
If multiple Employee Classes exist please provide details on each benefit/class.
#5 WORKSITE BENEFIT TAX STATUS OF EMPLOYEE CONTRIBUTIONS
Check If #5 Worksite Benefit Eligible Employee Description Is Same As The Health Plan
- Same As Health Plan
#5 WORKSITE BENEFIT PLAN ELIGIBLE EMPLOYEE DESCRIBED
In Example: Full-Time Employees working 30+ hours/week
Check If #5 Worksite Benefit Employee Participation Begin Date Is The Same As The Health Plan
- Same As Health Plan
#5 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION BEGINS
Check If #5 Worksite Benefit Employee Participatin End Date Is The Same As The Health Plan
- Same As Health Plan
#5 WORKSITE BENEFIT WHEN EMPLOYEE PARTICIPATION ENDS
Worksite benefits typically end as of date employee becomes ineligible.
#5 Name of Worksite Benefit Offered
#5 WORKSITE BENEFIT CLAIMS CONTACT
#5 WORKSITE BENEFIT CLAIMS CONTACT NAME #5 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS #5 WORKSITE BENEFIT CLAIMS CONTACT PHONE#

*Claims Address and Phone # are required.
Check All Other Fringe Benefits That Are Offered To Employees That Have To Comply With ERISA
- Select All
- Apprenticeship Program
- Burial Expense
- Business Travel Accident
- Executive Medical Coverage
- Fue Shots To Non-Medical Covered Participants
- Legal Plan (prepaid group)
- Long Term Care Plan
- Medicare Premium Subsidy
- Severance Pay
- Travel Accident

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BROKER INFORMATION
Agency Name
Agency Address
Street Address Address Line 2 City State ZIP Code
Agency Contact
First Last
Agency Contact Email
Agency Contact Phone

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DELIVERY AND BILLING INSTRUCTIONS
Deliverables Sent To*
- Select All
- Client Contact
- Broker Contact
- Other
Billing Sent To*
- Select All
- Client Contact
- Broker Contact
- Other

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Approval & Signature
Name
First Last
Email
Signature
Date
Date Format: MM slash DD slash YYYY
Untitled
Date
Date Format: MM slash DD slash YYYY
Date
Date Format: MM slash DD slash YYYY

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Company Name	Company Address	Company Phone#	Company FEIN#

Carrier	Plan Name	CMS Status (Credible/Non-Credible)

Carrier	Plan Name	CMS Status (Credible/Non-Credible)

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EMPLOYER INFORMATION

PLAN INFORMATION

FEDERAL NOTICES INFORMATION

WELLNESS INFORMATION

VARIABLE HOUR EMPLOYEE INFORMATION

COMPONENT BENEFITS PLAN(S) DESCRIPTION SECTION

GROUP HEALTH PLAN(S) DESCRIPTION

RETIREE HEALTH PLAN(S) DESCRIPTION

DENTAL PLAN(S) DESCRIPTION

VISION PLAN(S) DESCRIPTION

LIFE (AD&D) PLAN(S) DESCRIPTION

LTD PLAN(S) DESCRIPTION

STD PLAN(S) DESCRIPTION

FSA PLAN(S) DESCRIPTION

HRA PLAN(S) DESCRIPTION

EAP PLAN DESCRIPTION

WORKSITE BENEFITS

BROKER INFORMATION

Section Break

DELIVERY AND BILLING INSTRUCTIONS

Approval & Signature