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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:
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.

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