ICHRA Intake Form – Health Insurance Made Easy

Contact Information

Name *

Title *

Email Address *

Phone *

Plan AdministratorThe person who will be responsible for the administration of the ICHRA plan.Same as Contact

Protected Health Information DesigneeThe person who will be responsible for the proper handling of medical information protected under HIPAA lawSame as Contact

Plan Administrator

Name

Title

Email Address

Phone

Protected Health Information DesigneeThe person who will be responsible for the proper handling of medical information protected under HIPAA lawSame as Administrator

PHI Designee

Name

Title

Email Address

Phone

Company Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Fax

Website

Number of Employees *

EIN *

Form of Business *

State of Incorporation

CheckboxAffiliated Companies?

Affiliated Company(ies)

Affiliated Company EIN

Affiliated Company Name

New Plan or Amended Plan *New PlanAmended Plan

Effective Date of New Plan

Effective Date of Amended Plan

Effective Date of Original Plan

Eligibility *All employees regularly scheduled to work __ or more hours per week. 1 to 40 hours per week.

Waiting Period: *Employees are eligible the first day of the month coinciding with or next following __ consecutive days of employment. (90 Days from Hire Max)

Coordination *Will your ICHRA coordinate with a Health FSA?YesNo

Will your ICHRA coordinate with an HSA Plan?YesNo

Reimbursements available to: *Will the ICHRA be used to Reimburse Employee costs only?Employee OnlyEmployee + Dependants

Employee Only (annually) $Enter annual benefit limit per employee

Employee & Eligible Dependents (annually) $Enter annual benefit limits for Employee & Eligible Dependents

Reimbursements Categories *Reimbursements will be paid for the selected categories.Premium OnlyAllowed IRS 213(d) Medical, Dental and Vision expensesMedicare Premium Parts B, C, and D and supplementalMedicare out-of-pocket expenses including all IRS 213(d) medical, dental, vision expenses

Employee Classes *Will premium reimbursement be the same for all Employees?

Employee Class Description *

Pretax Extra PremiumIf your ICHRA does not cover 100% of premiums, will employees be able to pretax extra premium using a Section 125 Premium Only Plan?

Unused Funds *Will unused funds carryover to the next Plan Year?

Unused Funds DescriptionUse this space to describe carry over of unused funds. You may either carryover a percentage or dollar amount of unused funds.

Additional informationPlease tell us how you would like your new ICHRA Schedule of Benefits to be designed. We will review your notes for compliance issues and send you a follow-up plan design questionnaire with all allowed ICHRA plan options you can consider adding or omitting.

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