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1ACCOUNT INFORMATION
2PLAN INFORMATION
3ELIGIBILITY
4BENEFITS OFFERED
5MEDICAL
6PRESCRIPTION DRUG
7DENTAL
8VISION
9LIFE INSURANCE PLAN(S)
10SHORT TERM DISABILITY
11LONG TERM DISABILITY
12FSA
13HRA
14QSEHRA
15HSA
16ADOPTION ASSISTANCE
17PREMIUM CONVERSION PLAN
18OTHER COMPONENT BENEFITS
19FEDERAL NOTICES
20ADA WELLNESS
21COBRA
22HEALTH INSURANCE EXCHANGE
23MEDICARE PART D
24MHPAEA
25MICHELLE
26NEWBORNS
27NO SURPRISE BILLING
28PRIVACY PRACTICES
29SPECIAL ENROLLMENT RIGHTS
30SMM
31WHCRA
32DELIVERY INSTRUCTIONS
33AUTHORIZED SIGNERS
34BILLING AND PAYMENT
  • BASIC ACCOUNT INFORMATION

  • Drop files here or
    Max. file size: 8 MB.
      Please upload a logo file (JPEG, BMP, PNG)
    • LOCATION INFORMATION

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    • PLAN INFORMATION

    • General plan

    • in example: ABC Company Benefit Plan
      In general, you may wish to select a ‘New Plan’ if
      -All benefit plans are new.
      -You want to establish a new plan to create a clean break from past plans and practices.
      -You want to split a plan when an employer provides different benefits to different classes of employees.
      In general, you may want to select 'An amendment and restatement of an existing plan' if:,
      -The wrap document is being used to consolidate all benefit coverages into a single plan (e.g., adding life and dental coverage to a group health plan).
      -The provisions in the wrap document are updated to comply with new laws and new agency requirements, or benefit plans or other information have been changed or replaced.
      -An employer wants to continue its current benefit program and use the wrap document to verify that all types of coverage are contained in a single ERISA-covered plan with a single wrap plan document. (This is often the case when a Form 5500 has previously been filed indicating that the employer has a single plan.)
    • Welfare plan numbers begin with 501 and proceed consecutively. So, the second welfare plan of an employer would be 502, followed by 503, etc. A plan number can never be used more than once. If this is an ongoing plan, refer to the prior document or SPD, or if applicable, the most recently filed Form 5500.
    • MM slash DD slash YYYY
      In the case of an amended and restated plan, the effective date would be the date on which changes to specific plan provisions or benefit plans become effective. If this information is not available or this is a new plan, then the date which may be used is the date the wrap plan document is created.
      Generally, a plan year can be any twelve-month period selected by the plan sponsor. However, a plan can have a short plan year when there is a legitimate business purpose. This would include a short year for: the first plan year; a plan termination; or a merger of two plans that have conflicting plan years.
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
      The Plan Year can be any twelve-month period. The Plan Year does not have to match any insurance contract year, open enrollment period, or the employer’s fiscal year. Generally, however, most employers select a January 1 calendar year which matches the date of their open enrollment selections. The Wrap Plan Year does not have to match the Wrap Effective Date.
    • MM slash DD slash YYYY
    • Plan administrator

    • Agent of service

      An agent for service of process is a corporation's registered agent designated by a business entity to receive legal documents and lawsuits on behalf of the business entity within the state in which the agent's address is located.
    • Wellness program

    • Other participating employers

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    • Eligibility

      You may wish to create multiple sets of documents if different benefits are offered to different classes of employees (e.g., full-time vs. part-time). One way to address this is to create completely separate plans (each with their own plan numbers) for the different classes, rather than letting one group know that another has different benefits.
    • Eligibility Requirements

      In general terms, an “orientation period” is defined under the Affordable Care Act (ACA) as a period of up to one month that an applicable large employer (ALE) may add on to the beginning of a full-time employee’s waiting period for coverage eligibility.
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    • Benefits

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    • Medical Benefit

    • Medical plan carrier information

    • Grandfathered plan

    • Medical plan pre-tax contribution

    • Medical plan eligibility

    • Medical plan eligibility requirements

    • Medical plan accompanying benefit documents

    • Max. file size: 8 MB.
      Files must be under 8 MB. The only files accepted are Word, PDF, Excel, PowerPoint, & Zip
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    • Prescription Drug Benefit

    • Prescription Drug plan information

    • Prescription Drug plan pre-tax contributions

    • Prescription Drug plan eligibility

    • Prescription plan eligibility requirements

    • Prescription Drug accompanying benefit documents

    • Max. file size: 8 MB.
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    • Dental Benefit

    • Dental plan carrier information

    • Dental plan pre-tax contributions

    • Dental plan eligibility

    • Dental plan eligibility requirements

    • Dental plan accompanying benefit documents

    • Max. file size: 8 MB.
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    • Vision Benefit

    • Vision plan carrier information

    • Vision plan pre-tax contributions

    • Vision plan eligibility

    • Vision plan eligibility requirements

    • Vision plan accompanying benefit documents

    • Max. file size: 8 MB.
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    • Life Benefit

    • Life plan carrier information

    • Life plan pre-tax contribution

    • Life Plan eligibility

    • Life plan eligibility requirements

    • Life plan accompanying benefit documents

    • Max. file size: 8 MB.
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    • Short Term Disability Benefit

    • Short Term Disability plan carrier information

    • Short Term Disability plan pre-tax contribution

    • Short Term Disability plan eligibility

    • Short Term Disability plan eligibility requirements

    • Short Term Disability plan accompanying benefit documents

    • Max. file size: 8 MB.
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    • Long Term Disability Benefit

    • Long Term Disability plan carrier information

    • Long Term Disability plan pre-tax contribution

    • Long Term Disability plan eligibility

    • Long Term Disability plan eligibility requirements

    • Long Term Disability plan accompanying benefit documents

    • Max. file size: 8 MB.
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    • Flexible Spending Account ("FSA") Benefit

    • FSA plan administration information

    • FSA account eligibility

    • FSA account eligibility requirements

    • Additional FSA information

    • FSA plan accompanying benefit documents

    • Max. file size: 8 MB.
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    • Health Reimbursement Account ("HRA") Benefit

    • Primary HRA Plan Name2nd HRA Plan Name3rd HRA Plan Name 
    • HRA plan administration information

    • HRA eligibility

    • HRA eligibility requirements

    • Additional HRA information

    • HRA plan accompanying benefit documents

    • Max. file size: 8 MB.
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    • Qualified Small Employer HRA ("QSEHRA") Benefit

    • QSEHRA plan administration information

    • QSEHRA plan dates

      A short plan year followed by the 12 month regular period:
      A PCP can have a short plan year of less than twelve months when it is needed or a legitimate business purpose (e.g., the first plan year, or when, before the beginning of a plan year, the employer expects to have a substantial change in benefits mid-year and wishes to allow employees to make a new election at that time).

      A single regular 12 month period:
      The PCP Plan Year, in general, can be any twelve-month period and does not have to match any insurance contract year or the Wrap Plan Year. The PCP Plan Year is also the effective period for plan participants’ premium conversion contribution elections (e.g., January 1 through December 31), during which participants cannot change their elections unless certain specified events occur.
    • QSEHRA eligibility

    • QSEHRA eligibility requirements

    • QSEHRA plan accompanying benefit documents

    • Max. file size: 8 MB.
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    • Health Savings Account ("HSA") Benefit

    • HSA plan administration information

    • HSA Display Settings

    • Accompanying benefit documents

    • Max. file size: 8 MB.
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    • Adoption Assistance Benefit

    • Adoption Assistance plan administration information

    • Adoption Assistance eligibility

    • Adoption Assistance - Eligibility requirements

    • Adoption Assistance accompanying benefit documents

    • Max. file size: 8 MB.
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    • Premium Conversion Plan Benefit

    • Premium Conversion plan administration information

    • Premium Conversion PCP display settings

    • Premium Conversion PCP Plan Dates

    • The Effective Date could be the date on which the employer first offered a premium conversion and/or HSA contribution option, or the date on which certain amendments to the PCP became effective. The PCP Effective Date does not have to match the Effective Date for the Wrap Plan.
      A short plan year followed by the 12 month regular period:
      A PCP can have a short plan year of less than twelve months when it is needed or a legitimate business purpose (e.g., the first plan year, or when, before the beginning of a plan year, the employer expects to have a substantial change in benefits mid-year and wishes to allow employees to make a new election at that time).

      A single regular 12 month period:
      The PCP Plan Year, in general, can be any twelve-month period and does not have to match any insurance contract year or the Wrap Plan Year. The PCP Plan Year is also the effective period for plan participants’ premium conversion contribution elections (e.g., January 1 through December 31), during which participants cannot change their elections unless certain specified events occur.
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    • OTHER COMPONENT BENEFITS

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    • The following Section is a Questionnaire to determine which Federal Notices your plan is required to disclose to benefit participants. To Continue with this Section check the "CONTINUE WITH QUESTIONNAIRE" box.

    • Federal Notices

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    • ADA Notice Regarding Wellness Program

    • Need Help?

      Sentence will display as, 'Additional incentives of up to _________ may be available...'
    • Need Help?
      For guidance in answering this question, please see the 3rd paragraph of the sample notice. Example: 'participate in the XYZ Company yoga class'
      copy and paste the following link to your browser to view a copy of the Sample Notice for Wellness Programs

      https://www.eeoc.gov/regulations/sample-notice-employer-sponsored-wellness-programs
    • Need Help?
      For guidance in answering this question, please see the 3rd paragraph of the sample notice. Example: 'losing 15 pounds'
      copy and paste the following link to your browser to view a copy of the Sample Notice for Wellness Programs

      https://www.eeoc.gov/regulations/sample-notice-employer-sponsored-wellness-programs
    • Need Help?
      Sentence will display as, " In order to provide you with services under the wellness program, the only individual(s) who will receive your personally identifiable health information is (are) ....
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    • COBRA General Notice

      A qualified beneficiary is an employee, an employee's spouse, or an employee's dependent child who is covered by an employer-sponsored group health plan on the day before a qualifying event.
    • The answer in this text area will merge into the Spanish version of this notice..
    • The answer in this text area will merge into the Spanish version of this notice..
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    • Health Insurance Exchange Notice (for companies who offer a health plan)

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    • Medicare Part D Creditable Coverage Notice

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    • Mental Health Parity and Addiction Equity Act (MHPAEA) Disclosure

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    • Michelle's Law Notice

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    • Newborns’ and Mothers’ Health Protection Act Notice

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    • No Surprise Billing

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    • Notice of Privacy Practices

    • The answer in this text area will merge into the Spanish version of this notice..
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    • Special Enrollment Rights Notice

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    • Summary of Material Modifications Or No Material Modifications

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    • WHCRA Notice

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    • DELIVERY INSTRUCTIONS

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    • Authorized Signer

    • Reset signature Signature locked. Reset to sign again
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    • Billing and Payment


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