Transcript Superior State Administrators, Inc.

The HRA
Concept
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Recent IRS Guidance
Released July 26, 2002
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Qualifying
Requirements of an
HRA



Employer Contributions Only
Provide Reimbursement for
medical expenses of the employee
and his/her Dependents
May permit the carry forward of
unused amounts from one
coverage period to the next.
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Recent IRS Guidance





FSA Rules do not apply to HRAs
Reimbursements can be limited to
the account balance
Reimbursements may be limited to
a percentage of the Request for
reimbursement
No 12 month requirement for a
plan year
Medical expenses do not have to
be incurred during the period of
coverage.
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Recent IRS Guidance

Individuals Permitted to receive
reimbursements
 Employee
 Former
Employee (Plan Option)
 COBRA qualified beneficiaries
 Spouses
 Dependents
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Recent IRS Guidance

FSA Ordering Rule
 IRS
is flexible when it comes to the
HRA and FSA order of payment of
reimbursements
 Past regs. Required the HRA funds
to be used first
 Plan documents may specify that
the FSA may be used prior to the
exhaustion of the HRA funds
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Recent IRS Guidance

Using a HRA and a Cafeteria Plan
 The
HRA plan can be offered as a
benefit inside a Cafeteria Plan
 Only Employer contributions are
allowed
Note:Using the HRA as a benefit in a
Cafeteria Plan works very well as a
Defined Contribution plan
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Recent IRS Guidance

Multiple Contributions Levels
 An
employer can offer multiple
contribution levels as long as the
plan does not discriminate in favor
of the Highly Compensated / Key
employees
 Example
• Single
• 2-Person
• Family
$40
$60
$80
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Recent IRS Guidance

COBRA Concerns
 Employee
Premium calculation
 Based
on the employers
contribution
 Contribution changes will effect the
premium required to continue
COBRA
 Terminated
employees can not
elect to only continue the HRA
 Terminated employees are not
required to elect the HRA if the
elect COBRA for the health
insurance
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Recent IRS Guidance

HIPAA Issues
 At
this time we have no guidance
regarding HIPAA
Agent
Presentation
Enter Agency Name
Brings to you:
Vantage Flex, LLC.
and
The HRA Concept
www.vantageflex.com
About Vantage Flex,LLC.


12 years in the industry.
9 years doing Administration.
 Section
125 Administration.
 Section 105 Administration.
 Section 132 Administration.
 HRA Administration.


10,000+ Employees under
Administration.
Sister company to Vantage Financial
Solutions specializing in Investment
Products.
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About Insurance Co.





(Name) has been providing Group
health benefits since ________
AM Best Rating ____
Financial Number
(Name) was founded in 1892.
Training On-line


www.xxxxxxxxxxxxx.com
Forms On-line

www.xxxxxxx.com
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Identifying the Problem




Rates dramatically increasing
Employee’s are unaware of the
true cost of health care.
Prescription Drug usage has
increased due to the increase
marketing efforts of the
Pharmaceutical companies.
Employer’s are looking to agents
for help and the agent isn’t sure
where to turn.
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Solutions

Provide a unique concept coupled
with a competitive product that
saves the employer money and
provides the same or better
benefits to the employees.
 New
HRA Concept
 Health

Reimbursement Accounts
Employee Cost Awareness
 Employee
first dollar benefits with
cost sharing in every claim until the
plan deductible is met.
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The New Concept
Health Reimbursement Account (HRA)

The HRA concept enables the employer to
take a higher deductible plan and make a
contribution to a medical reimbursement plan
for each employee.

The HRA funds are then used to offset the
high deductible at any level the employer
wants.

The HRA concept enables the employer to
limit the eligible expenses to Core Health
Benefits only or open it up to all Section 213
eligible expenses.

No “use it or lose it” the account can roll at
the year end.

In most cases this can be done for less cost
than the current plan.
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Employee Cost Awareness

Employee first dollar benefits with
cost sharing in every claim

The HRA concept enables the employer
to set a reimbursement percentage limit.

By limiting the reimbursement the
employee receives a benefit with each
incurred expense but also share’s in the
cost.
Note: If set at the correct percentage, the
employee will satisfy the entire Deductible
when they have used all of their HRA
funds.
Employee Census
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
The following census was used to generate the
quotes for the plans in the following slides.
Employee
1
2
3
4
5
6
7
8
9
10
11
Sex
M
M
M
F
M
F
M
M
M
M
M
Age
54
45
42
38
43
46
44
50
48
36
50
Coverage
2-Person
Family
Family
Single
Single
2-person
Family
2-Person
Single
2-Person
Single
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
Example
Plan Comparison Monthly
Current Plan
Proposed Plan
$500 Ded then 80/60
$1650 Ded. Then 100/90
0
50% to $825
$756.25
Premium
$5,753
$3,827
In-Network
OOP
Fam. OOP
$1,500
$3,000
$825
$1,650
Out-of-Network
OOP
Fam. OOP
$4,000
$8,000
$1,375
$2,750
Plan
HRA Plan Pays
HRA Contribution
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Monthly
$6,000
$5,000
$4,000
$3,000
Employer Savings
HRA Funds
Premium
$2,000
Employer
Savings
Proposed
Plan
$0
Current
Plan
$1,000
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Annual Results
Guaranteed
Employer Plan
Savings $14,037
Projected
Employer Plan
Savings $17,667
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Step One
First $1650 / year
$5,000,000 Lifetime Maimium
Core Insurance
Deductible
In-Network Core Insurance Paid at 100%
After $1,650 Deductible.
$1650 In-Network
$1650 Out-of Network
Out-of Network Core Insurance Paid at 90%
after $1,650 Deductible to next $5,500
Then 100%
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Step Two
First $1650 / year
Core Insurance
Deductible
$5,000,000 Lifetime Maimium
In-Network Core Insurance Paid at 100%
After $1,650 Deductible.
$1650 In-Network
$1650 Out-of Network
HRA
Employer Contribution
$825
Paid at 50% to $1650
Out-of Network Core Insurance Paid at 90%
after $1,650 Deductible to next $5,500
Then 100%
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Step Three
First $1650 / year
Core Insurance
Deductible
$5,000,000 Lifetime Maimium
In-Network Core Insurance Paid at 100%
After $1,650 Deductible.
$1650 In-Network
$1650 Out-of Network
HRA
Employer Contribution
$825
Paid at 50% to $1650
Out-of Network Core Insurance Paid at 70%
after $1,650 Deductible to next $5,500
Then 100%
FSA Used for non-reimbursed expenses up to
$2,000 per year for medical, prescriptions,
dental & vision care.
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Why Use (enter the Agency name here)

Proprietary Products - HRA

Single Source for many Products

Employers are looking for a
solution and we have many!
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Plan Setup and
Enrollment.
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T h e F u tu re o f E m p lo yee B en efit A d m in istratio n
H e a lt h R e im b u r s e m e n t A c c o u n ts
In th e c u rren t m ark et o f g ro u p h ealth in su ran ce, w e see a n in crea sed in terest in co st co n tain m e n t.
M an y sm all e m p lo y ers are co m b a tin g co sts b y d ra m atically in creasin g d ed u ctib le s an d
estab lish in g a d efin ed co n trib u tio n ap p ro ach to co st sh arin g w ith th e e m p lo y ees. T o so ften th e
im p act o n e m p lo y ees, so m e co m p an ies are im p le m e n tin g a S elf-In su red H ealth R eim b u rsem e n t
A cco u n t (H R A ) in ad d itio n to th e g ro u p h ealth in su ran ce. V an tag e F le x , L L C . can im p le m en t a n d
ad m in ister th e se typ e s o f p lan s.
Im p le m en ta tio n serv ices in clu d e:

P erso n al e m p lo yer ev alu atio n an d reco m m en d atio n o f p lan d esig n .

T h e p ro d u ctio n o f a p lan d o cu m e n t, su m m ary p la n d escrip tio n an d e m p lo y ee fo rm s.
A d m in istra tio n serv ices in clu d e :

A ll th e n ecessary n o n d iscrim in atio n te stin g

A d ju d icatio n o f cla im s

O n lin e access o f acco u n tin g rep o rts fo r th e e m p lo yer

O n lin e e m p lo y ee claim fo rm co m p letio n

O n lin e claim h isto ry fo r th e em p lo y er an d e m p lo yee

O n lin e acco u n t b alan ce s accessib le 2 4 /7

F ax a claim (7 7 5 ) 5 2 1 -7 6 7 6 o p tio n

R eim b u rse m e n t sc h ed u le m atch in g p a yro ll

E m ail n o tice o f R eim b u rse m en t rep o rts to th e e m p lo y er

Y ear en d rep o rtin g p rep aratio n
A d m in istra tio n can b e d iv id ed in to claim s p ro cessin g , rep o rtin g a n d co m p lia n ce.
C laim s P ro cessin g
E m p lo yees m a y su b m it claim s o n th e fo rm s p ro v id ed b y th e e m p lo y er, th e y ca n p rin t claim fo rm s
fro m th e V an ta g e F le x w eb p ag e, o r th e y ca n en ter claim s o n th e ir p erso n al o n lin e ad m in istratio n
site. T h e em p lo y ee can access th e ir acco u n t b y click in g o n th e C lie n t L o g in lin k at
v an ta g e fle x .co m . S u ffic ien t e v id en ce o f in c u rred ex p en se s m u st b e attach ed to th e claim fo rm o r
th e reim b u rse m en t p a y m en t m a y b e d ela yed .
If V an ta g e F le x d eterm in es th at a su b m itted claim is n o t elig ib le fo r reim b u rse m e n t u n d er th e P lan ,
a w ritte n n o tice p ro v id in g th e reaso n fo r th e d en ial is fo rw ard ed to th e e m p lo yee. V a n ta g e F lex ,
L L C . d o es n o t h av e a n y resp o n sib ility to in v estig a te th e acc u rac y o r tru th fu ln ess o f an y claim
su b m itted to u s. T h e resp o n sib ility fo r claim v a lid ity is p laced o n th e e m p lo y ee.
R ep o rtin g
T h ere are tw o areas o f rep o rtin g : E m p lo yee a n d E m p lo yer.
E m p lo yee rep o rtin g is acco m p lish ed th ro u g h th e e m p lo yee acco u n t access to th eir w eb b ased
acco u n t. T h e e m p lo yee h as all claim a n d acco u n tin g h isto ry av a ilab le to th e m 2 4 /7 .
T h e em p lo yer h as ad m in istrativ e access to th eir acco u n t a n d can d o w n lo ad an d p rin t rep o rts o n an
as n eed ed b asis.
C o m p lia n ce
S elf-F u n d ed M ed ical E x p en se R e im b u rse m en t P lan s are su b ject to th e n o n d iscrim in a tio n
reg u latio n s co n tain ed in IR S C o d e S ectio n 1 0 5 . V an tag e F lex , L L C . co n d u c ts n o n d iscrim in atio n
testin g a n n u ally , u p o n th e clo se o f o p en e n ro llm e n t. T h e e m p lo yer w ill b e resp o n sib le fo r
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H e a lth R e im b u r s e m e n t A c c o u n t
D efin itio n
A H ealth R eim b urse m e nt A cco u nt is a n y p la n o r arrange m ent u nd er w hich a n e m p lo yer
reim b urse s an e m p lo yee fo r uninsured health o r accid ent exp en ses inc urred b y the e m p lo yee o r his
d ep end ents. H ealth o r accid ent exp enses in th is co nte xt are d efined in In ternal R e ve nue C o d e
S ectio n 2 1 3 (e). T he m o st co m m o n typ e o f S ectio n 1 0 5 p lan is a self-fu nd ed health p lan, w here the
e m p lo yer ha s cho se n no t to insure health care b enefits a nd to self-fu n d the se b ene fits rather tha n
p ay p re m iu m s to a n in surer. S ectio n 1 0 5 p lans are also freq uently fo u nd insid e S ectio n 1 2 5
C afeteria P lan s in the fo rm o f M ed ical F le xib le S p e nd in g A cco u nts (F S A s). It is p erm issib le,
ho w ever, to im p le m e nt a H ealth R eim b urse m e nt A cco u nt alo n g sid e a co nve ntio nal health
insurance p la n (to reim b urse am o u nts no t co vered b y in sura nce) and o utsid e o f a ca feteria p lan.
W h a t a re th e a d v an tag es o f S ectio n 1 05 p la n s?
S ectio n 1 0 5 p lans o ffer ad vanta ges to b o th the e m p lo yer and the e m p lo yees. T he m ed ical exp e nse
reim b urse m e nts are ta x d ed uctib le b y the e m p lo yer and the em p lo yer has fle xib ility in the d esign
o f the p lan 's p ro visio ns, such a s estab lishin g m a xim u m a m o un ts fo r reim b urse m ent a nd settin g
eligib ility req uire m en ts fo r p articip atio n. T he b iggest ad va ntage to e m p lo ye es is tha t the p lan 's
reim b urse m e nt p a ym e nts are no t co n sid ered to b e taxab le inco m e to the e m p lo yees, p ro vid ed that
the y ha ve no t ta ken a m ed ical exp e nse d ed uctio n fo r the se am o unts o n their p erso nal tax return.
C a n th e em p loy er a d m in ister th e S ectio n 105 p la n ?
T he sho rt answ er is yes, b ut w e d o no t reco m m e nd self-ad m in istratio n fo r tw o reaso ns – first,
co rrectly d eterm inin g w hether exp e nse s m eet the criteria u nd er C o d e S ectio n 2 1 3 fo r
reim b urse m e nt req uires e xten sive k no w led ge, creating the risk o f no nco m p lia nce d ue to im p ro p er
reim b urse m e nts; seco nd ly, w h e n the e m p lo yer m u st d en y a reim b urse m e nt req ue st, it can generate
an ad versarial situatio n b etw een e m p lo yer and e m p lo yee w h ich is no t d esirab le. V anta ge F le x,
L L C . o ffers cla im s ad m inistratio n services fo r suc h p lan s at a very reaso nab le co st.
W h a t a re th e req u irem en ts for S ection 1 05 p la n s?
T he p rincip al req uirem e nts to q ualify und er S ectio n 1 0 5 are to ad op t a w ritten p la n d o cu m en t, all
p articip ants m u st b e e m p lo yees, e xp en ses to b e reim b ursed m u st no t b e sub ject to reim b urse m e nt
und er an y hea lth insura nce p o lic y, and the p la n m ust m eet the no nd iscrim inatio n req uire m en ts
sp ecified u nd er the C o d e.
W h a t a re th e n o n d iscrim in a tio n req u irem en ts u n d er S ectio n 105 ?
T he p lan m u st no t d iscrim inate in fa vo r o f high ly co m p e nsa ted e m p lo yees w ith resp ect to
eligib ility to p articip ate o r b enefits p ro vid ed und er the p la n.
A p la n d iscrim inate s as to eligib ility u nless it b ene fits:
1 . 7 0 % o r m o re o f all e m p lo yee s, o r
2 . 8 0 % o r m o re o f all e m p lo yee s eligib le to b enefit u nd er the p lan, if 7 0 % o r m o re o f all
e m p lo yees are eligib le to b enefit u nd er the p lan, o r
3 . A gro up o f e m p lo yees d escrib ed in IR C S ectio n 4 1 0 (b )(2 )(A )(I) that is fo und to b e a
no nd iscrim inato ry classificatio n in acco rd ance w ith P ro p . T reas. R eg. 1 .4 1 0 (b )- F o r these
p urp o ses, there m a y b e exclud ed fro m co nsid eratio n an y e m p lo yees w ho ha ve no t
co m p leted three years o f service, p art-tim e e m p lo yee s w ho se c usto m ary w ee kly
e m p lo ym en t is less than 3 5 ho urs, e m p lo yees co vered b y a co llective b argainin g
agree m e nt, and no nresid e nt alien s.
A m ed ical reim b urse m en t p lan w ill no t d iscrim inate a s to b enefits if the typ e and a m o u nt o f
b enefits availab le to hig hly co m p e nsated p articip ants a nd their d ep end ents are also availab le o n the
sa m e b asis fo r all o ther p articip ants and the ir d ep end ents. T his test is ap p lied b y lo o kin g at
availab le b ene fits rather tha n actual b ene fit p a ym e nts und er the p la n.
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S ervice P rop osal
Im p lem en ta tio n serv ices in clu d e:


P erso nal em p lo yer ev alu atio n and reco m m en d atio n o f p lan d esig n .
T h e p rod u ction of a p lan do cu m en t, su m m ary p lan d escrip tion an d
em p lo yee fo rm s.
A d m in istra tio n serv ices in clu d e :










A ll th e n ecessary n o n discrim in atio n testing
A d ju dication o f claim s
O n lin e access o f acco unting rep orts for th e em p lo yer
O n lin e em p lo yee claim fo rm co m p letio n
O n lin e claim h isto ry fo r th e em p lo yer and em p lo yee
O n lin e acco un t b alan ces accessib le 24 /7
F ax a claim (7 75 ) 52 1-767 6 o ption
R eim b u rsem en t sch edule m atch in g p ayro ll
E m ail no tice o f R eim b u rsem en t rep o rts to the em p lo yer
Y ear end rep o rting p reparatio n
F ees fo r S erv ices P ro v id ed :
S etu p F ee
A n nu al F ee (secco nd + years)
5 500 F ee
M on th ly P er P articip ant
$ 300
$ 300
$ 150 (if requ ired)
$ 5 .0 0
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A d o p tio n A g ree m en t C h ec k list
(H R A )
S e c tio n : E m p lo y e r In fo r m a tio n
S e c tio n : E lig ib ility
N a m e o f E m p lo ye r
a. ______________________________
b. ______________________________
E m p lo ye r's A d d re ss
a . (S tre e t) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
b . (C ity)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
c . (S ta te )_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
d . (Z ip )_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
e . (T e le p h o n e ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
f. (E m a il) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E m p lo ye r's T a x ID N o .
a. ______________________________
P la n N u m b e r
_______________
E m p lo ye r's P rin c ip a l O ffic e
a . (sta te )_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P la n In fo rm a tio n
 a . N e w P la n
 b . A m e n d m e n t a n d R e sta te m e n t
P la n Y e a r
a . B e g in s _ _ _ _ /_ _ _ _ /_ _ _ _
b . E n d s _ _ _ _ /_ _ _ _ /_ _ _ _
Is first y e a r a sh o rt P la n Y e a r
 c . Y e s, b e g in n in g _ _ _ _ _ _ _ _ _ _ _ _
 d . N /A
E ffe c tiv e D a te (s) In itia l E ffe c tiv e D a te
a . _ _ _ _ /_ _ _ _ /_ _ _ _
E m p lo ye r E n tity
 a . S C o rp o ra tio n
 b . C o rp o ra tio n
 c . P a rtn e rsh ip
 d . S o le P ro p rie to rsh ip
 e . G o v e rn m e n ta l E n tity o r C h u rc h
 f. N o n -P ro fit O rg a n iz a tio n
 g . L im ite d L ia b ility C o rp o ra tio n
E lig ib le C la ss o f E m p lo ye e s
 a . A ll E m p lo ye e s w h o sa tisfy
e lig ib ility re q u ire m e n ts
 b . S a la rie d E m p lo ye e s o n ly
 c . H o u rly E m p lo y e e s o n ly
 d . A ll E m p lo y e e s e x c e p t
 1 . C o m m issio n e d E m p lo ye e s
 2 . U n io n E m p lo y e e s
 3 . L e a se d E m p lo ye e s
 4 . P a rt-tim e E m p lo ye e s,
e x p e c te d to w o rk le ss th a n _ _ _
h o u rs p e r w e e k
 5 . N o n re sid e n t A lie n s
 6 . E m p lo ye e s n o t e lig ib le u n d e r
E m p lo ye r's g ro u p m e d ic a l p la n
 7 . O th e r
C o n d itio n s fo r E lig ib ility
 a . S a m e a s E m p lo ye r's g ro u p m e d ic a l
p la n
 b . F o r first P la n Y e a r o n ly, a n y o n e
e m p lo ye d o n th e e ffe c tiv e d a te o f th e P la n
is e lig ib le , th e re a fte r
 c . F o r a ll ye a rs, e lig ib ility is a s
fo llo w s:
 d . D a te o f h ire (n o se rv ic e re q u ire d )
 e . _ _ ye a rs a fte r d a te o f h ire
 f. _ _ d a ys a fte r d a te o f h ire
 g . _ _ m o n th s a fte r d a te o f h ire
E n try D a te
 a . F irst d a y o f th e p a y p e rio d n e x t
fo llo w in g d a te re q u ire m e n ts w e re m e t
 b . D a te c o n d itio n s fo r e lig ib ility a re
m et
 c . F irst d a y o f P la n Y e a r fo llo w in g
d a te re q u ire m e n ts w e re m e t
 d . F irst d a y o f m o n th fo llo w in g d a te
re q u ire m e n ts w e re m e t
 e . S a m e a s E m p lo ye r's g ro u p m e d ic a l
p la n
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S ectio n : C o m p e n sa tio n a n d C o n trib u tio n s
C o m p en satio n received d urin g P lan Y ear shall
b e...
 a. B ase co m p en satio n (e xclud e s
o vertim e, co m m issio ns a nd b o nuse s)
 b . O ther
E m p lo yer C o n trib utio n s. F o r each P lan Y ear,
E m p lo yer w ill co ntrib ute...
 a. _ _ _ % o f co m p en satio n p er
P articip ant
 b . $ __ p er P articip ant
 c. D iscretio nary
 d . O ther
A N D , the co ntrib utio n s shall b e m ad e...
 e. A t b egin ning o f P lan Y ear
 f. P ro rata each p ay p erio d
S ectio n : B en efit O p tio n s
P lan w ill reim b urse...
 a. A ll S ec tio n 2 1 3 eligib le exp e nses.
 b . C o re exq enses O nly
 c. C o re health insurance d ed uctib le
o nly
 d . O ther_ _ _ _ __ _ __ _ __ _ __ _ __ _ __ _
P lan w ill reim b urse at the rate o f ...
 a. 1 0 0 % o f eligib le exp enses.
 b . 5 0 % o f eligib le exp ense s
 c. _ _ __ _ o f eligib le exp enses
S ectio n : R o ll O p tio n s
E m p lo yees have the o p tio n to ...
 a. R o ll all fund s le ft in the acco u nt at
the end o f the year.
 b . R o ll _ _ _ % o f the fu nd s.
 c. R o ll _ _ _ % o f the fund s to a
m ax im u m o f $ _ _ _ _ _ __ _ .
 d . N /A N o fu nd s w ill ro ll.
S ectio n : A ffilia ted E m p lo y ers
W ill A ffiliated E m p lo yers exec ute this P lan
 a. N /A o r N o
 b . Y es, includ e sig nature line s fo r
1 . (N am e)
2 . (S treet)
3 . (C ity) (S tate) (Z ip )
4 . (ID N o .)
W ill there b e a seco nd A ffiliated E m p lo yer
 a. N o
 b . Y es
1 . (N am e)
2 . (S treet)
3 . (C ity) (S tate) (Z ip )
4 . (ID N o .)
W ill there b e a third A ffiliated E m p lo yer
 a. N o
 b . Y es
1 . (N am e)
2 . (S treet)
3 . (C ity) (S tate) (Z ip )
4 . (ID N o .)
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S E R V IC E A G R E E M E N T
C E P R O V ID E R :
th
vic e a g re e m e n t a u th o rize s V a n ta g e F le x , L L C ., 2 0 1 2 1 0 S tre e t, M e n o m in e e , M I 4 9 8 5 8 , h e re a fte r k n o w n a s
v ic e P ro v id e r w ith th e a b o ve lis te d p rim a ry b u s in e s s a d d re s s , to p e rfo rm th e d u tie s o f C o -A d m in is tra to r a s
d in th e A d o p tio n A g re e m e n t fo r th e C lie n t C o m p a n y's C a fe te ria P la n .
T C O M P AN Y :
____________________________________
_____ ______________________________
____________________________________
CES REQUESTED
x ib le S p e n d in g A c c o u n t (F S A )
e a lth R e im b u rs em e n t A c c o u n t (H R A )
o P a n 1 2 5 A d m in is tra tio n a n d R e p o rtin g (P O P )
ACT CLAU SES:

It is a g re e d th a t th e S e rvic e P ro vid e r s h a ll p e rfo rm th e s e rvic e s re q u e ste d a s in d ic a te d a b o ve fo r th e C lie n t. A ll em plo ye e c e ns u s
d a ta a n d re late d b e n e fit in fo rm atio n s h a ll b e fu rn is h e d to th e S e rvic e P ro vid e r b y th e C lie n t. T h is d ata m ust b e s u bm itte d w ith in tw o
(2 ) m o nth s a fte r th e s ig n in g
of th is a g re em e n t. T h is tim e m a y b e e xte n d e d s h o u ld e a c h e xte n s io n m e e t w ith th e m u tu a l
a g re e m e n t o f b o th th e C lie nt a n d th e S e rvic e P ro vid e r. If th e tim e lim it is n o t m e t a n d a n e xte n s io n is n o t o bta in e d , th is a g re em e nt
m a y b e c a n c e le d b y th e S e rvic e P ro vid e r, a n d th e C lie nt s h a ll fo rfe it th e d o w n p a ym e n t s p e c ifie d b e lo w . It is fu rth e r a g re e d th at th e
c lie n t g ive s p e rm is s io n to th e S e rvic e P ro vid e r to u s e th em as a refe re n c e .

T h e S e rvic e P ro vid e r a g re e s to e xe rc is e re a s o n a b le c a re a n d c a u tio n in re p o rtin g a ll d ata c o n ta in e d in th e P la n . H o w e ve r, th e
S e rvic e P ro vid e r m a k es n o e xp re s s e d o r im plie d g u a ra n te es as to th e a cc u ra c y of th e re p o rts if in acc u ra te d a ta is s u p p lie d . T h e
C lie n t, th e re fo re , a g re e s to c h e ck all d a ta s u p p lie d fo r c o nte n t a n d a c cu ra c y.
D E N T IA L IT Y S T A T E M E N T :
b tain e d b y th e S e rvic e P ro vid e r from th e C lie n t s h a ll b e h e ld in c o nfid e n c e a n d s h a ll n ot b e m a d e k n o w n to o th e r p e rs o ns , p a rties , o r
e s w ith o u t w ritte n p e rm is sio n from th e C lie n t.
:
nc e D u e w ill b e b a s e d o n th e ac tu al n um b e r of em p lo ye e s p a rticip a tin g a n d/o r e lig ib le w ith th e C om p a n y. T h e d o w n p a ym e n t is n o n e . A ll b illin gs a re D u e w ith in 3 0 d a ys from b illin g d a te . If p a ym e n t is n o t re c e ive d w ith in 3 0 d a ys , Inte re s t w ill b e c om p o u n d e d a t a ra te o f
n th ly.
a c h e d Q u o te fo r a c o m p le te e x p la n a tio n o f th e F e e s .
ze d b y: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a te : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ig n a tu re : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a te : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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IN F O R M A T IO N C H E C K L IS T
S ection 105 / H R A
_____ A D O P T IO N A G R E E M E N T _____ S E R V IC E A G R E E M E N T
E M P L O Y E E C E N S U S (C E N S U S F O R A L L E L IG IB L E E M P L O Y E E S )
_____A D D R E S S E S
_____ B IR T H D A T E S
_____ H IR E D A T E
_____ P A Y C H E C K FR E Q U E N C Y
_____ G R O S S W A G E S
PER CHECK
_____ O FF IC E R / O W N E R
_____ S O C IA L S E C U R IT Y N U M B E R S
_____ E M A IL A D D R E S S E S (if available)
_____ C O N T R IB U T IO N S C H E D U L E (D a y o f the m onth the C ontribution w ill be
m ade)
_____ C O N T R IB U T IO N A M O U N T
B E N E F IT S
_____ P O L IC Y # 'S
(In su ran ce B illin g an d b en efit o u tlin e)
_____ P H O N E # 'S
_____ C O N T A C T P E R S O N
C O N T A C T P E R S O N (P A Y R O L L )
__________________________________________
P H O N E _________________________________________
E X T .__________________
E M A IL A D D R E S S
________________________________________________________
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R eq u est fo r R eim b u rsem en t
th
2 012 10 S treet , M eno m in ee M I 49 858
P h on e: (8 00 ) 871 -9 0 11
F a x C la im s to: (775 ) 521 -767 6
E m p lo yer N a m e :
E m p lo yee N a m e:
SSN :
A d d ress:
S ectio n 1 2 5 F lex P la n
H ea lth R eim b u rsem en t A cco u n t
_ _ _ _ _ M ed ical C laim
_ _ _ _ _ D ep en d en t C are C laim
N ame
S elf / S p o u se / D ep end ent
_ _ _ _ _ H R A C laim
D ate o f S ervice
F ro m To
D escrip tio n
D o llar A m o u nt
T o tal:
$
$
$
$
$
$
$
T o th e b est o f m y k n o w led ge an d b elief, m y statem en ts in th e req u ested ex p en ses are co m p lete an d tru e. I
am req u estin g reim b u rsem en ts o n ly fo r eligib le ex p en ses in cu rred d u rin g th e ap p licab le p lan year fo r,
m yself an d m y eligib le d ep en d en ts. I certify th at th ese ex p en ses h av e n o t b een an d w ill n o t b e reim b u rsed
u n d er an o th er em p lo yer sp o n so red b en efit p lan an d w ill n o t b e claim ed as an in co m e tax d ed u ctio n .
A lso , I certify th at th ese ex p en ses h av e n o t b een p rev io u sly reim b u rsed u n d er th is p lan . I au th o rize th at
m y p lan acco u n t m a y b e red u ced b y th e am o u n t o f th e req u ested reim b u rsem en t.
_ ___ ___ ___ ___ ___ _ _____ ___ ___ ___ ___ _ ____ ___ ___ __
E m p lo yee S ig nature
D o no t w rite in the b o x b elo w .
D ate R eceiv ed b y A d m in istrato r ___ ___ /_ ___ __/___ ___
N o tes:
_ ___ __/___ ___ /_ ___ __
D ate
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Open
Discussion