Employer Name: Date: Effective Date: Street Address: City: State: Zip: State of Incorporation: Federal Tax ID: Type of Employer Entity (please check one): C Corporation S Corporation Partnership Sole Proprietorship Limited Liability Company Non-Profit Organization Government Church Primary Contact: Title: Billing Contact: Title: Phone: Fax: Phone: Fax: Payroll Contact: Payroll Frequency: Is Payroll Outsourced? Email: Date of 1st payroll deductions: Yes Phone: No If Bi-Weekly: 24 or 26 If yes, please identify vendor: Is COBRA Outsourced? Broker’s Phone: Additional Contact(s) for Broker: Yes Broker’s Email: Name: No Broker (Agent) Name: Phone: If yes, please identify vendor: Broker’s Company Name: Email: III. PLAN INFORMATION HSA INFORMATION HSA monthly admin fee paid by: # of eligible employees: Transfer from other vendor: Employer # of HSA participants: Yes Employee No Is the employer contributing to If yes, are the contributions: ER contribution applied: employees’ HSAs? Flat Dollar Annually Yes Matching Quarterly No Other Monthly With each payroll Other Is there a Sect. 125 Cafeteria plan Is a new Sect. 125 Cafeteria plan Is there a limited FSA in place? document in place? document required? Yes Yes Yes No No No Additional Comments: FSA INFORMATION Plan Year Begin: End: Benefits offered: Approx. number of eligible Health FSA employees: Mid-year Takeover Yes No Limited Purpose FSA Limited Purpose FSA with Post Approx. number of participants: Deductible expense FSA Contribution Annual Maximum: Dependent Care FSA IRS Max Other $ Parking/Transit
Employer Name: Date: Effective Date: Street Address: City: State: Zip: Federal Tax ID: State of Incorporation: Type of Employer Entity (please check one): C Corporation S Corporation Partnership Sole Proprietorship Limited Liability Company Non-Profit Organization Government Church Primary Contact: Phone: Title: Fax: Billing Contact: Phone: Title: Fax: Payroll Contact: Email: Phone: Payroll Frequency: Date of 1st payroll deductions: If Bi-Weekly: 24 or 26 Is Payroll Outsourced? Yes No If yes, please identify vendor: Is COBRA Outsourced? Yes No If yes, please identify vendor: Broker’s Phone: Broker’s Email: Broker (Agent) Name: Broker’s Company Name: Additional Contact(s) for Broker: Name: Phone: Email: III. PLAN INFORMATION HSA INFORMATION HSA monthly admin fee paid by: Employer Employee # of eligible employees: # of HSA participants: Transfer from other vendor: Yes No Is the employer contributing to employees’ HSAs? Yes No If yes, are the contributions: Flat Dollar Matching Other ER contribution applied: Annually Quarterly Monthly With each payroll Other Is there a Sect. 125 Cafeteria plan document in place? Yes No Is a new Sect. 125 Cafeteria plan document required? Yes No Is there a limited FSA in place? Yes No Additional Comments: FSA INFORMATION Plan Year Begin: End: Mid-year Takeover Yes No Benefits offered: Health FSA Limited Purpose FSA Limited Purpose FSA with Post Deductible expense Dependent Care FSA Parking/Transit Approx. number of eligible employees: Approx. number of participants: FSA Contribution Annual Maximum: IRS Max Other $
Implementation%20Handbook%20for%20HSA%20FSA%20FINAL.docx