Legal Name of Employer
Federal Tax ID / Effective Date / # of Eligible Employees
Business Address
Mailing Address (if different than above)
Contact Information
Account Administrator(The main employer contact for the implementation process)
Name / Title
Phone / Fax / Email
Partner/ Broker Information
Contact Name and Firm Name
Address
Phone / Fax / Email
Who is paying the Set-up Fee? Broker Client
Account Details
- If multiple plans are offered, accounts pay in the order selected below.
- HRA plans must specify the timing for when funds are available to employees and which expenses are covered.
- All plans must run for 12 months; short plan years cannot be administered.
- If multiple plans are offered, they must run concurrent plan years.
- All FSA plans include DCAP. FSA plans allow Grace Period, which extends expiration of the funds by two-and-a-half months.
- If offering an HSA with additional account(s), the HSA cannot be listed as the first account.
First Account (Pays First) / Second Account / Third Account
HRA* / HRA* / HRA*
FSA / FSA / FSA
HSA / HSA / HSA
*HRA Details - HRA plans must specify the timing for when funds are available to employees and which expenses are covered.
Timing for when funds are available to employees: Upfront On a Cycle
Expenses Covered: All 213d Expenses Medical and Prescription Expenses Only Medical Expenses Only
FSA RolloverOptions
Allow $500 Rollover (cannot also offer grace period) Do Not Allow $500 Rollover No FSA Offering
Client Communication- Have you verified that the client understands:
HSA contributions, funds to pay FSA and HRA claims, and administrative fees are all paid via ACH.
How the employee submits receipts for substantiation after they use the payment card or pay out of pocket for an eligible expense.
Notes on Sales Process/Comments - Please provide any information the CYC implementation team should know.
CYC Internal Use Only
Code:
Date Received:
Date Emailed: / Date Agreements Approved:
Date Enrollment Completed:
Plan Document Sent:
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