HRA / FSA PLUS Online Sign Up Form

1.

Legal Name of Company Sponsoring Plan:
2.

Business Entity Type:
3.

Principal Business Activity:
4. Federal Employer Identification Number:
5.

A. HR Contact Person:    
     E-Mail:
B. Manager:
     E-Mail:
C. Owner:
     E-Mail:    
6. A. Street Address (No PO Boxes):
     City: State: Zip:
B. Mailing Address (If different from above)
     City: State: Zip:
7.

Phone: Fax: E-mail:

8. Effective Date: This HRA or FSA Plan will be:
a. A new plan effective as of (date)
b. An amendment and restatement of a previously established Section 125 Plan of the employer.
(1) This amendment and restatement is effective as of (date)
(2) State the effective date of the original plan
(3) State the plan number (consult your last Form 5500 for this number assigned to your plan):
9.

Plan Year End: - if applicable
10.

Employer's Principal Office - This HRA or FSA Plan shall be governed under the laws of the:
11.

Benefits - The benefits selected below shall be included in the HRA or FSA Plan:

Medical expenses not covered by insurance
Health and other  (select coverages below):
Health Insurance
Dental Insurance
Vision Care Insurance
Mass Transit and Qualify Parking
Accountable Education Expenses
Other (specify):
12.

Legal Name(s) of Affiliated Company(ies) that will be covered by this Plan:

13.

Total Number of Employees Participating in Medical Plan:

14.

Payroll is Prepared:

In house
Others:
Payroll Provider E-Mail
Pricing Information
15.

HRA Plan one time set up fee applies per employee participating in Medical Plan. (Minimum set up fee $500 or $15 per eligible employee which ever is higher)

FSA Plan 

Monthly Recurring Charge: $  per participant(s), charges includes HRIS.

Agent / Broker or Consultant Name

Agent / Broker's  e-mail:

16.

New Plan set-up is delivered via your company's web site, and enrollment is done by your broker or consultant.

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