ERISA Wrap Application - Admin America

1EMPLOYER INFORMATION

2PLAN INFORMATION

3FEDERAL NOTICES INFORMATION

4WELLNESS / VARIABLE HOUR EES INFORMATION

5HEALTH PLAN(S) DESCRIPTION

6RETIREE HEALTH PLAN(S) DESCRIPTION

7DENTAL PLAN(S) DESCRIPTION

8VISION PLAN(S) DESCRIPTION

9LIFE/AD&D PLAN(S) DESCRIPTION

10LTD PLAN(S) DESCRIPTION

11STD PLAN(S) DESCRIPTION

12FSA PLAN DESCRIPTION

13HRA PLAN DESCRIPTION

14EAP PLAN DESCRIPTION

15WORKSITE BENEFIT PLAN(S) DESCRIPTION

16BROKER INFORMATION

17AUTHORIZED AND PREPARED BY

18DELIVERY AND BILLING INSTRUCTIONS

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
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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
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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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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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AUTHORIZED AND PREPARED BY
Your Name*
First Last
Your Email*

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DELIVERY AND BILLING INSTRUCTIONS
Deliverables Sent To*
- Select All
- Client Contact
- Broker Contact
- Other
EverWrap
Price:
EverWrap Restatement
Price:
Total
$0.00
Billing Contact Name*
First Last
Billing Contact Email*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Contact Phone*
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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Company Name	Company Address	Company Phone#	Company FEIN#

Company Name	Company Address	Company Phone#	Company FEIN#

Company Name	Company Address	Company Phone#	Company FEIN#

Company Name	Company Address	Company Phone#	Company FEIN#

Questions

8:30 am – 5:00 pm EST

Admin America, Inc.

770-992-5959 800-366-2961

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

AUTHORIZED AND PREPARED BY

DELIVERY AND BILLING INSTRUCTIONS

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

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

Name of Component Benefit Plan(s)

Name of Component Benefit Plan(s)