FSA Intake Form

Flexible Spending Intake Form The information gathered through this Intake Form will be used to draft the Adopting Empl...

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Flexible Spending Intake Form

The information gathered through this Intake Form will be used to draft the Adopting Employer’s Plan, consisting of the Basic Plan Document and the Adoption Agreement. The Adopting Employer hereby makes the following representations and selections: BSI Representative: EMPLOYER INFORMATION

EMPLOYEES

Employer Name: Address:

There were more than fifty (50) Employees in the last 12 months? Yes No

City, State Zip: Phone/Fax Number: Type of Business Entity:

There were more than twenty (20) Employees in the last calendar year? Yes No

/

PLAN INFORMATION: Is this a mid-year takeover? Yes If so, when is the current Plan Year End?

State of Incorporation: Tax ID Number: If the Plan Administrator is different than the Employer, please provide the following: Name: Address: City, State Zip: Phone/Fax Number: /

Will BSI administer run-out?

No

Yes

No

Check the one that applies (check only one box): The Plan is intended to comply with ERISA. The Plan is not intended to comply with ERISA, and any references to ERISA do not bind the Plan to comply with ERISA.

EMPLOYEES Approx. Number of Eligible Employees:

Plan Number: Addendum(s) Attached?

Yes

No

Approx. Number of Participants in Plan: CONTACTS Claim Funding Contact: Title: Phone/Fax Number: Divisions (if any): Include in Welcome call?

Daily Administrative Contact: Title: Email: Phone/Fax Number: / Divisions (if any): Include in Welcome call? Yes No Monthly Billing Contact: Title: Phone/Fax Number: Divisions (if any): Include in Welcome call?

Email: / Yes

No

Email: / Yes

No

If you have any additional contacts, please include their Name, Title, email, Phone and fax number on an additional sheet. BROKER/CONSULTANT Agency/Firm: Tax Identification Number: Representative:

Name: Address: City, State Zip Phone/Fax No.: Email Address: Client

Document Delivery to: BAA Received

Yes

No

-

/ Broker/Consultant

Include Broker in Welcome call?

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Both Client and Broker/Consultant Yes

No

Flexible Spending Intake Form

DEFINITIONS Effective Date means: Is this a Restatement: Yes No If Yes, original Effective Date: Is this a Mid-Year Takeover: Yes No Employer means: Subsidiaries and/or affiliates participating in the Plan are:

Plan Name means: Plan Year commences on the first day of and ends on the last day of . A short plan year begins on and ends on . This year’s Open Enrollment Period begins on . Open Enrollment Type: BSI Online Other Online Enrollment CSV or XLS File Paper/Manual

Optional Benefit(s) means (check all that apply):

Non-Reimbursement:

Reimbursement:

Group Medical Benefit Group Dental Benefits Group Term Life and/or Group AD&D and/or Voluntary Life Benefits HSA Contribution Feature

Dependent Care Expense Reimbursement Plan Medical Expense Reimbursement Plan Individual Premium Feature Limited Scope Medical Expense Reimbursement Plan

and ends on

HRIS File

Optional Debit Card Yes No

Other: Group Medical Plan is:

Fully-insured

Self-insured

Group Dental Plan is:

Fully-insured

Self-insured

ELIGIBILITY AND PARTICIPATION Eligibility requirements are as follows (check and complete only those that apply):

Special rule for new hires: As provided in the Basic Plan Document. (BSI’s standard

Length of service: Minimum number of hours: Employment Classification: Other:

language reads: “Unless specifically provided otherwise in the Adoption Agreement, for new hires, an Eligible Employee shall execute and deliver to the Plan Administrator within thirty (30) days of employment, such written application. In this situation, participation in this Plan is retroactive to the date of hire pursuant to Cafeteria Plan Regulations. However, salary reduction contributions to pay for coverage during the period preceding the submission of the application shall be taken prospectively from compensation paid following submission of the application.)

Entry Date means: Eligibility

Other:

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Flexible Spending Intake Form

CONTRIBUTIONS Salary reduction contributions shall occur: Every payroll period. Only two payroll periods per month. Please indicate which payroll periods will be skipped Payroll Frequency:

Weekly

Bi-Weekly (26/yr)

Monthly Bi-Weekly (24/yr)

Amount of the Employer Contribution for the Plan Year is: None. $ per Participant. The Employer Contribution shall be provided as follows: Per pay period. Per month Per quarter. Per year on or about the first day of the Plan Year. Other:

Semi-Monthly Other

First pay date of the Plan Year: Second pay date of the Plan Year: Last pay date of the Plan Year:

Restrictions: Round Payroll Deductions: ______________ If payroll reductions exceed election amount for the year, do you adjust? Yes No If yes, adjust payroll reductions: ______________ ELECTIONS Initial Elections: As provided in the Basic Plan Document. (See the

Irrevocable Election rules are modified as follows: As provided in the Basic Plan Document. (See the

References section at the end of this document – “Section 5.1 Initial Election” to view details.)

References section at the end of this document – “Section 5.4 Elections Irrevocable” to view details.)

Other:

Other:

Annual Elections: As provided in the Basic Plan Document. (See the References section at the end of this document – “Section 5.2 Subsequent Annual Elections” to view details.)

Other: ADMINISTRATION Plan Administrator means: As provided in the Basic Plan Document. (See the

GENERAL PROVISIONS General law – State of

References section at the end of this document – “Section 6.1 Plan Administrator” to view details.)

Other:

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Flexible Spending Intake Form

MEDICAL EXPENSE REIMBURSEMENT PLAN Claims Run-Out period: days

Reimbursement of Medical Expenses following termination of participation: Expenses incurred while a Participant may be reimbursed if submitted within the Claims Run-Out Period identified in this section. Expenses incurred while a Participant may be reimbursed within 30 days following termination of participation.

Dependent means: As provided in the Basic Plan Document. (BSI’s standard document reads: “Means an individual (e.g., Spouse, child, domestic partner, etc.) who qualifies as a “dependent” under the terms and conditions of the applicable plan document governing the Group Medical Benefits. To the extent a Dependent is provided coverage under the Group Medical Benefits and that Dependent is not the Participant’s Spouse or Tax Dependent, the tax consequence of such coverage shall be addressed as described in Section 4.2.” Please see the References section – 4.2 Imputation of Include to view language.)

Other: 2 ½ Month Claims Grace Period Does not apply to ME Account. Applies to the ME Account.

Other:

Other Medical Expense Reimbursement Plan limitations are: None. Other:

Medical Expense means: As provided in the Basic Plan Document. (BSI standard reads “Means, unless otherwise limited in the Adoption Agreement, an expense incurred during the applicable Plan Year by a Participant, Spouse, or Dependent for medical care as defined in Section 213 of the Code, excluding premiums for health coverage, health reimbursement arrangements (“HRAs”), medical savings accounts (“MSAs”), and long-term care coverage. Medical care generally refers to the diagnosis, cure, treatment, or prevention of disease or for the purpose of affecting any structure or function of the body. Also included, are reasonable transportation expenses for and essential to medical care. Effective January 1, 2011, “Medical Expense” shall include drugs and medicine only to the extent allowed by Section 106(f) of the Code.)

If you are choosing the BSI OneCard or Green FSA Program, please complete the following for autoadjudication: Rx co-pays: Yes Generic: $ Brand Formulary: $ Non-Formulary: $ Other: $

No

Medical Co-Pays: Yes No Office Visit: $ Emergency Room: $ Urgent Care Visit: $ Other: $ If you have multiple medical co-pay plans and/or Rx plan copays, please attach a schedule.

Other: Annual Minimum Election: $ Annual Maximum Election: $ For a short Plan Year, the maximum reimbursement is: Not applicable. Pro-rated. Unchanged. For Participants joining the Plan mid-Plan Year, the maximum is: Pro-rated. Unchanged. DEPENDENT CARE EXPENSE REIMBURSEMENT PLAN Claims Run-Out period: days

Annual Minimum Election: $

Reimbursement of Dependent Care Expenses following termination of participation: Expenses incurred while a Participant may be reimbursed if submitted within Claims Run-Out Period identified above. Expenses incurred while a Participant may be reimbursed if submitted within 30 days following termination of participation. Expenses incurred during the Plan Year (whether while a Participant or after participation ceases) may be reimbursed if submitted within Claims Run-Out Period identified above. Other:

Annual Maximum Election: $ Other dependent care limitations are as follows: N/A Other:

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Flexible Spending Intake Form

INDIVIDUAL PREMIUM FEATURE Claims Run-Out period: days

BSI does not administrate this benefit Reimbursement of Individual Premium Expenses following termination of participation: Dependent means: Expenses incurred while a Participant may be reimbursed As provided in the Basic Plan Document. if submitted within Claims Run-Out Period identified in Other: this section. Insurance Contract means: Expenses incurred while a Participant may be reimbursed As provided in the Basic Plan Document. within 30 days following termination of participation. Just specialty coverages (e.g., cancer, vision, hospital Expenses incurred during Plan Year (whether while a indemnity, transplant, dental). Participant or after participation ceases) may be Just individual major medical; to the extent permitted reimbursed if submitted within Claims Run-Out Period under law. identified above. Other: Other: HSA CONTRIBUTION FEATURE BSI does not administrate this benefit High Deductible Health Plan means: As provided in the Basic Plan Document. Other: LIMITED SCOPE MEDICAL EXPENSE REIMBURSEMENT PLAN BSI does not administrate this benefit Claims Run-Out period: days Reimbursement of Limited Scope Medical Expenses following termination of participation: Dependent means: Expenses incurred while a Participant may be reimbursed As provided in the Basic Plan Document. if submitted within the Claims Run-Out Period identified Other: in this section. Expenses incurred while a Participant may be reimbursed Limited Scope Medical Expense means: within 30 days following termination of participation. As provided in the Basic Plan Document. Other: Other: 2 ½ Month Claims Grace Period Annual Minimum Election: $ Does not apply to Limited Scope ME Account. Applies to the Limited Scope ME Account. Annual Maximum Election: $ For a short Plan Year, the maximum reimbursement is: Not applicable. Pro-rated. Unchanged.

Other Limited Scope Medical Expense Reimbursement Plan limitations are as follows: None. Other:

For Participants joining the Plan mid-Plan Year, the maximum is: Pro-rated. Unchanged. INTERNAL USE ONLY Billing Effective Date:

PEPM-1st Account: $

PEPM Paid by:

Debit Card: $

Next Rate Renewal Date:

Broker Comm: $

Other, describe:

Notes:

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