Employer Application
(POP, FSA, HSA, & TRN) / 6377 S. Revere Parkway,Suite 350
Centennial, CO80111
303.221.2783 Ph
303.221.2785 Fx
Company Name & Address:Contact Name:______
______Telephone #:______
______Fax#:______
______Email:______
Brokerage Firm ______Consultant’s Name: _________
Please list the names, addresses and tax I.D numbers of any affiliated employers that will adopt this plan:
______
Eligibility
Eligibility Waiting Periods: (enter # of days before eligible)
Eligibility Waiting Period Premiums Healthcare FSA Dependent Care FSA
Current Employees: ______Days ______Days ______Days
New Employees: ______Days ______Days ______Days
Eligible Employees: Full Time: Part Time:
#of hours required for eligibility status: ______(if left blank 40 hours per week will be used)
Entry Date: 1st of the month after meeting eligibility requirements unless noted otherwise here.
Will the 2 ½ months Grace Period be incorporated? Yes No
Does the ER agree to a standard 90 day Run Out period? Yes No
Will the employer contribute to the spending plans? Yes No If yes, how much $______
Will PBS administer your group’s HSA? Yes No Custodian: ______
Please name either an individual or committee as the point of contact for HIPAA Privacy Concerns with whom PBS may, from time to time, discuss Protected Health Information, if necessary to adjudicate a claim under any component of this plan. Our HIPAA Privacy Contact will be:
______
Discrimination Testing Information
Section 125 and 105 plans may not discriminate in favor of highly compensated employees in terms of ability to participate or as to contributions and benefits. Planned Benefit Systems will perform the necessary discrimination tests on an annual basis to help ensure the Employer’s plans are in compliance. In order to perform these tests, the Employer agrees to provide required information including but not limited to the status and election amounts of participating employees. Please note that 2% or more owners in Sub Chapter S corporations are not eligible to participate in Section 125 or 105 plans. Likewise, Partners in a Partnership or Limited Liability Corporation or Limited Liability Partnerships are not eligible to participate in Section 125 or 105 plans.
The employer must complete the ACH Authorization Agreement & Administrative Agreement before claims will be processed.
The employer understands that Planned Benefit Systems will be preparing a Plan Document and Summary Plan Description (if elected above) for all components of the plan. The employer further understands that the plan document will allow an automated enrollment in the Premium Conversion Plan and a claims submittal period of 90 days after plan year end. The employer agrees to distribute a Summary Plan Description to each participant in the plan. It is understood that any unanswered sections of this document may result in errors in the plan produced by this form. Planned Benefit Systems, Inc. makes no representation or warranty of any kind as to the legal effect, sufficiency or tax qualification of any document utilizing PBS’ format. I hereby release PBS from any and all liability attributable to any legal, tax or other defect in the requested documents.
Signed:______Date:______
By:______