Service Signup Application

Personal Information:
Type of Service:





Company Information:
Are Affiliated Employers Adopting This Plan?
Agent Information:
Cafeteria Plan Information:
The second plan year will run for 12 months and will start on the day after the Plan Year End listed.
Are Union Employees Eligible:
Core Benefits Offered









      
If Dental is Offered Does it Include Orthodontia?
Is This a Takeover of an Existing Plan?
Is This a Mid Year Take Over?
There is no Medical FSA Maximum set by the DOL, the IRS or any of the Section 125 or 105 regulations. Employers typically limit the amount available based on their willingness to assume the risk that an employee will terminate employment after spending more than they have contributed to the Medical FSA. Please contact us if you have any questions.
Are the Eligibility Requirements the Same as Those Listed for the Cafeteria Plan Above?
Are Union Employees Eligible:
Dependent Care FSA:
The second plan year will run for 12 months and will start on the day after the Plan Year End listed.
Is This a Takeover of an Existing Plan?
Is the Participation in the Employer's Health Plan Required to be Enrolled in the HRA?
Annual Employer Contribution Per Participant:
Can Participants Carry Over Unused Funds?
Maximum Carryover:
Are Participants Required to Meet a Deductible Before the HRA Funds Become Available?
Is the HRA Integrated With a High Deductible Health Plan?
Will the HRA Cover All IRS Allowable Expenses?
The IRS allows all Section 213d expenses including vision, dental, deductibles, co-pays and certain procedures not covered by insurance for a full list please contact us.
Which of the Following Will Be Covered?






      
Are the Eligibility Requirements the Same as Those Listed for the Cafeteria Plan Above?
Are Union Employees Eligible:
Funding:
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.