Service Signup Application

Personal Information:
First Name:
Last Name:
Telephone Number:
Email Address:
Type of Service:
Medical & Dependent Care FSA
Transit & Parking
Healthcare Reimbursement Arrangement
Premium Only Plan
COBRA
HSA
Company Information:
Company Name:
Telephone Number:
Fax Number:
Address:
City:
State:
Zip:
Finance Contact Name:
E-mail Address:
HR Contact Name:
Email Address:
State of Legal Construction:
Federal Tax ID #:
Type of Legal Entity:
Are Affiliated Employers Adopting This Plan?
Yes No
Agent Information:
Agent:
Enrollment Contact:
Address:
City:
State:
Zip:
Telephone Number:
Fax Number:
Email Address:
Send Invoice To:
Cafeteria Plan Information:
Original Effective Date:
Plan Year Start:
Plan Year End:
The second plan year will run for 12 months and will start on the day after the Plan Year End listed.
Waiting Period:
Date of Eligibility:
Required Working Hours Per Week:
Are Union Employees Eligible:
Yes No
Core Benefits Offered
Health
Dental
Vision
Group Term Life
Disability
Cancer
Accident
Hospital Income
Medical Gap
Critical Illness
Other
      
If Dental is Offered Does it Include Orthodontia?
Yes No
Type of Health Insurance Available:
Plan Year Start:
Plan Year End:
The following plan year will run for 12 months and will start on the day after the Plan Year End listed.
Is This a Takeover of an Existing Plan?
Yes No
Original Effective Date:
Is This a Mid Year Take Over?
Yes No
Date of First Pay Check With a Pre-tax Withholding for the New Plan Year:
Number of Pays Per Year:
Number of Withholdings Per Year:
Dates to Skip:
Maximum Medical FSA Election Allowed:
There is no Medical FSA Maximum set by the DOL, the IRS or any of the Section 125 or 105 regulations. Employers typically limit the amount available based on their willingness to assume the risk that an employee will terminate employment after spending more than they have contributed to the Medical FSA. Please contact us if you have any questions.
What Will the Medical FSA Cover?
Are the Eligibility Requirements the Same as Those Listed for the Cafeteria Plan Above?
Yes No
Waiting Period
Date of Eligibility:
Required Working Hours Per Week:
Are Union Employees Eligible:
Yes No
Dependent Care FSA:
There is no risk to the employer under the Dependent Care FSA. We will set the Maximum allowed to the IRS Maximum of $5000 per family per year and we will use the same eligibility information listed under the Cafeteria Plan Section above. If there are any deviations or special notes about the Dependent Care FSA please list them here.
Plan Year Start:
Plan Year End:
The second plan year will run for 12 months and will start on the day after the Plan Year End listed.
Is This a Takeover of an Existing Plan?
Yes No
Original Effective Date:
Is This a Mid Year Take Over?
Yes No
Is the Participation in the Employer's Health Plan Required to be Enrolled in the HRA?
Yes No
Annual Employer Contribution Per Participant:
Single:
Employee/Spouse:
Employee/Child:
Family:
When are Funds Available to Participants?
Year Does not Match the Plan Year Selected Please List the Date that the Deductible Should be Replenished Each Year:
If the First Plan Year is a Short Plan Year the Participants' Accounts Will Be:
Participants Who Join the Plan Mid Plan Year Receive:
Can Participants Carry Over Unused Funds?
YesNo
Maximum Carryover:
Percentage: Dollar Amount:
Are Participants Required to Meet a Deductible Before the HRA Funds Become Available?
YesNo
If Yes Please Describe:
For Expenses Covered Under Both the FSA and the HRA Which Account Pays First?
If a Participant Terminates or Becomes Ineligible for the HRA Their Unused Amounts:
Is the HRA Integrated With a High Deductible Health Plan?
YesNo
Will the HRA Cover All IRS Allowable Expenses?
YesNo
The IRS allows all Section 213d expenses including vision, dental, deductibles, co-pays and certain procedures not covered by insurance for a full list please contact us.
Which of the Following Will Be Covered?
Vision
Dental
Prescriptions
Doctors
Hospitals
Lab
Chiropractic
Other
      
Please List Any Additional Information About Covered or Excluded Expenses:
Are the Eligibility Requirements the Same as Those Listed for the Cafeteria Plan Above?
YesNo
Waiting Period:
Date of Eligibility:
Required Working Hours Per Week:
Are Union Employees Eligible:
Yes No
Funding:
Bank Name:
Routing Number:
Account Number:
Account Type:
We hereby authorize Grant Benefits, DBA Flex Facts, to initiate debits and/or credits to or from our Bank Account listed above. These funds will be used to pay debit card and manual claim reimbursements under the Accounts signed up for through this application. There will be an initial $1 non refundable pre-note charged to this account. In the event that a direct deposit is returned for insufficient funds a $25 fee will be charged. This authorization is to remain in effect until written notice is provided to Grant Benefits to change the bank account or terminate the administration. Grant Benefits shall have 30 days to comply with the written request.


I agree with the terms and conditions listed above.