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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

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    • PLAN INFORMATION

    • If DBA applies, please include DBA Name.
    • Company NameCompany AddressCompany Phone#Company FEIN# 
      List Subsidiary Information
    • Company NameCompany AddressCompany Phone#Company FEIN# 
      List Subsidiary Information
    • Company NameCompany AddressCompany Phone#Company FEIN# 
      List Subsidiary Information
    • Company NameCompany AddressCompany Phone#Company FEIN# 
      List Subsidiary Information
    • 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.)
      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.
    • MM slash DD slash YYYY
      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.
      The person or company designated to accept service of process on behalf of the company.
    • The person or company designated to accept service of process on behalf of the company.
    • 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 address in which the participant can obtain a copy of the Privacy Notice.
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    • FEDERAL NOTICES INFORMATION

    • CarrierPlan NameCMS Status (Credible/Non-Credible) 
    • CarrierPlan NameCMS Status (Credible/Non-Credible) 
      Some health plans may require a participant to select a primary care physician (PCP).
    • "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.
    • 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? e.g. Part-Time Employees
      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.
    • HSA PLAN CLAIMS CONTACT NAMEHSA PLAN CLAIMS CONTACT ADDRESSHSA PLAN CLAIMS CONTACT PHONE# 
      Name of HSA Bank
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    • WELLNESS INFORMATION

      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.
    • In Example: Incentives such as gift cards and/or premium incentives. No such rewards are considered to be outcome based.
    • 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.
    • Indicate who will receive information such as "a registered nurse," "a doctor," or "a health coach"
    • VARIABLE HOUR EMPLOYEE INFORMATION

      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.
    • (Initial Measurement Period may not exceed 13 months)
    • In Example: 1st of Month Following Date of Hire
    • 1-90 days (Initial Measurement Period and Administrative Period may not exceed 13 months)
    • In Example: 1st of Month Following End of Administrative Period.
    • In Example: 12 Months
    • In Example: 12 Months
    • 3-12 months
    • 1-90 days
    • 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

    • Name of Component Benefit Plan(s) 
      Provide name of the component benefit plan(s); e.g. Cigna Group Health Plan.
    • If multiple Employee Classes exist please provide details on each benefit/class.
    • Claims paid by is the entity that funds the claims; e.g. fully insured plan would be funded by Insurer.
    • "Services Provided" is the entity that administers claims.
    • "Source of Plan Contributions" refers to contributions of insurance premium.
    • In Example: Full-Time Employees working 30+ hours/week
    • Example: Employees who are not considered Full-Time or Seasonal.
    • HEALTH PLAN CLAIMS CONTACT NAME; E.G. UHC RIVER VALLEYHEALTH PLAN CLAIMS MAILING ADDRESSHEALTH PLAN CLAIMS PHONE# 
      Example: Cigna Global Health Options
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      • RETIREE HEALTH PLAN(S) DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the component retiree benefit plan.
      • Claims paid by is the entity that funds the claims; e.g. fully insured plan would be funded by Insurer.
      • "Services Provided" is the entity that administers claims.
      • "Source of Plan Contributions" refers to contributions of insurance premium.
      • RETIREE HEALTH PLAN CLAIMS CONTACT NAME; E.G. UHC RIVER VALLEYRETIREE HEALTH PLAN CLAIMS MAILING ADDRESSRETIREE HEALTH PLAN CLAIMS PHONE# 
        Example: Cigna Global Health Options
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      • DENTAL PLAN(S) DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the component dental benefit plan.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • Benefits funded by is the entity that funds the claims; e.g. fully insured plan would be funded by Insurer.
      • "Services Provided" is the entity that administers claims.
      • "Source of Plan Contributions" refers to contributions of insurance premium.
      • In Example: Full-Time Employees working 30+ hours/week
      • Example: Employees who are not considered Full-Time or Seasonal.
      • DENTAL PLAN CLAIMS CONTACT NAMEDENTAL PLAN CLAIMS MAILING ADDRESSDENTAL PLAN CLAIMS PHONE# 
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      • VISION PLAN(S) DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the component vision benefit plan.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • Benefits funded by is the entity that funds the claims; e.g. fully insured plan would be funded by Insurer.
      • "Services Provided" is the entity that administers claims.
      • "Source of Plan Contributions" refers to contributions of insurance premium.
      • In Example: Full-Time Employees working 30+ hours/week
      • Example: Employees who are not considered Full-Time or Seasonal.
      • VISION PLAN CLAIMS CONTACT NAMEVISION PLAN CLAIMS MAILING ADDRESSVISION PLAN CLAIMS PHONE# 
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        Source of Plan Contributions Is 100% Employer Paid.
        Source of Plan Contributions Is 100% Employer Paid.
        Source of Plan Contributions Is 100% Employee Paid.
        Source of Plan Contributions Is 100% Employee Paid.
      • LIFE (AD&D) PLAN(S) DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the component Life & AD&D benefit plan.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • "Services Provided" is the entity that administers claims.
      • In Example: Full-Time Employees working 30+ hours/week
      • Life & AD&D benefits typically end as of date employee becomes ineligible.
      • Example: Employees who are not considered Full-Time or Seasonal.
      • BASE LIFE (AD&D) PLAN CLAIMS CONTACT NAMEBASE LIFE (AD&D) PLAN CLAIMS MAILING ADDRESSBASE LIFE (AD&D) PLAN CLAIMS PHONE#VOLUNTARY LIFE (AD&D) PLAN CLAIMS CONTACT NAMEVOLUNTARY LIFE (AD&D) PLAN CLAIMS MAILING ADDRESSVOLUNTARY LIFE (AD&D) PLAN CLAIMS PHONE# 
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      • LTD PLAN(S) DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the component LTD benefit plan.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • "Services Provided" is the entity that administers claims.
      • "Source of Plan Contributions" refers to contributions of insurance premium.
      • In Example: Full-Time Employees working 30+ hours/week
      • LTD benefits typically end as of date employee becomes ineligible.
      • Example: Employees who are not considered Full-Time or Seasonal.
      • LTD PLAN CLAIMS CONTACT NAMELTD PLAN CLAIMS CONTACT ADDRESSLTD PLAN CLAIMS CONTACT PHONE# 
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      • STD PLAN(S) DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the component STD benefit plan.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • "Services Provided" is the entity that administers claims.
      • "Source of Plan Contributions" refers to contributions of insurance premium.
      • In Example: Full-Time Employees working 30+ hours/week
      • STD benefits typically end as of date employee becomes ineligible.
      • Example: Employees who are not considered Full-Time or Seasonal.
      • STD PLAN CLAIMS CONTACT NAMESTD PLAN CLAIMS CONTACT ADDRESSSTD PLAN CLAIMS CONTACT PHONE# 
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      • FSA PLAN(S) DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the component Flexible Spending benefit plan.
      • In Example: Full-Time Employees working 30+ hours/week
      • Does the employer contribute "seed money" into the participant's FSA account.
      • Healthcare FSA benefits typically end as of date employee becomes ineligible.
      • Dependent Care FSA benefits typically end as of end of the plan year.
      • Example: Employees who are not considered Full-Time or Seasonal.
      • FSA PLAN CLAIMS CONTACT NAMEFSA PLAN CLAIMS CONTACT ADDRESSFSA PLAN CLAIMS CONTACT PHONE# 
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      • HRA PLAN(S) DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the HRA Plan
      • In Example: Employees Participating In The UHC PPO Plan.
      • HRA PLAN CLAIMS CONTACT NAMEHRA PLAN CLAIMS CONTACT ADDRESSHRA PLAN CLAIMS CONTACT PHONE# 
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      • EAP PLAN DESCRIPTION

      • Name of Component Benefit Plan(s) 
        Provide name of the EAP Plan.
      • Example: Employees who are not considered Full-Time or Seasonal.
      • EAP PLAN CLAIMS CONTACT NAMEEAP PLAN CLAIMS CONTACT ADDRESSEAP PLAN CLAIMS CONTACT PHONE# 
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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
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • In Example: Full-Time Employees working 30+ hours/week
      • Worksite benefits typically end as of date employee becomes ineligible.
      • #1 WORKSITE BENEFIT CLAIMS CONTACT NAME#1 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS#1 WORKSITE BENEFIT CLAIMS CONTACT PHONE# 
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • In Example: Full-Time Employees working 30+ hours/week
      • Worksite benefits typically end as of date employee becomes ineligible.
      • #2 WORKSITE BENEFIT CLAIMS CONTACT NAME#2 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS#2 WORKSITE BENEFIT CLAIMS CONTACT PHONE# 
        *Claims Address and Phone # are required.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • In Example: Full-Time Employees working 30+ hours/week
      • Worksite benefits typically end as of date employee becomes ineligible.
      • #3 WORKSITE BENEFIT CLAIMS CONTACT NAME#3 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS#3 WORKSITE BENEFIT CLAIMS CONTACT PHONE# 
        *Claims Address and Phone # are required.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • In Example: Full-Time Employees working 30+ hours/week
      • Worksite benefits typically end as of date employee becomes ineligible.
      • #4 WORKSITE BENEFIT CLAIMS CONTACT NAME#4 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS#4 WORKSITE BENEFIT CLAIMS CONTACT PHONE# 
        *Claims Address and Phone # are required.
      • If multiple Employee Classes exist please provide details on each benefit/class.
      • In Example: Full-Time Employees working 30+ hours/week
      • Worksite benefits typically end as of date employee becomes ineligible.
      • #5 WORKSITE BENEFIT CLAIMS CONTACT NAME#5 WORKSTIE BENEFIT CLAIMS CONTACT ADDRESS#5 WORKSITE BENEFIT CLAIMS CONTACT PHONE# 
        *Claims Address and Phone # are required.
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      • BROKER INFORMATION

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      • AUTHORIZED AND PREPARED BY

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      • DELIVERY AND BILLING INSTRUCTIONS


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