Paperwork Submission Instructions To begin the implementation process, the following forms must be completed and returned to CONEXIS:

Transcription

1 New Client Set-up Forms Paperwork Submission Instructions To begin the implementation process, the following forms must be completed and returned to CONEXIS: New Client Application Cafeteria Plan Information Form CONEXIS Banking Set-up and ACH Authorization Form This form is used to set up the banking processes for paying claims submitted by your participants UMB ACH Authorization Form This form is used to set up the banking processes to pay for benefit card transactions Voided check from each employer account reflected on the ACH authorization forms above Division Contact Information Form (where applicable) If you need to use separate bank accounts to pay claims or card transactions based on your divisions, you must complete the Division Contact Information Form and a separate CONEXIS Banking Set-Up and ACH Authorization Form and UMB ACH Authorization Form for each additional division. Signed and executed CONEXIS Service Agreement Please completed forms to laimplementations@conexis.com.

2 New Client Application Section A Employer Information Company Name DBA (Doing Business As) Federal Tax ID Number - FEIN Address Requested effective date City State Zip Nature of Business Section B Contact Information Contact Type Contact Name Title Phone Fax Address 1. Executive 2. Primary FSA 3. Payroll 4. Other 5. Other Which contact(s) should receive the invoice for CONEXIS services (mark all that apply)? Section C Broker/Consultant Information Broker/Consultant Name Agency Name Agency FEIN Address City State Zip Phone Number Fax Number Address Account Executive/Account Manager Name Phone Number Fax Number Address Who is the primary Agency contact for this employer for CONEXIS purposes? Broker/Consultant Account Executive/Account Manager Section D HIPAA Authorization The following Named Contacts List identifies all individuals to whom CONEXIS may provide protected health information (PHI) in the performance of its duties as set forth in the Confidentiality Exhibit of the Administrative Services Agreement (Client may use additional pages if needed, provided they reference the Confidentiality Exhibit and the effective date). All individuals requiring access to the CONEXIS Web site must be included on the list below or access to the CONEXIS Web site will not be granted. Contact Name Title Phone Address Web Access Section E Employer Representative Form completed by: Name Title Phone Number Read Only Full ne Read Only Full ne Read Only Full ne Read Only Full ne Read Only Full ne

3 Cafeteria Plan Information Form Section A General Plan Information IMPORTANT: All fields in this section are required. The information provided in this section will be used to create the plan document and Summary Plan Description (SPD) for your plan. These documents are required by law. CONEXIS will provide these documents to you or you may choose to use your own. If you choose to use your own documents, you must still complete all fields in this section. Company Name In which state is the company incorporated/domiciled? Total Number of Eligible Employees Entity Type (check one) C-Corporation S-Corporation Partnership Sole Proprietorship LLC Other (specify) Partners in a partnership, 2% shareholders in an S-corporation, members of an LLC and Sole-Proprietors may not participate in a Cafeteria Plan Are there any additional adopting employers of this plan? If so, please list them here (separate company names by a semi-colon): Plan Name (e.g., ABC Inc. Cafeteria Plan, ABC Inc. Flexible Benefits Plan, etc) Plan Year Start Date: Plan Year End Date: Original Effective Date of any Cafeteria Plan Will company use its own plan document/spd? If yes, effective date of company s plan document/spd? ERISA requires that all welfare benefit plans be given a plan number for identification purposes. Plan numbers for these plans begin at 501 and increase sequentially for each additional plan. Cafeteria plans are welfare benefit plans and therefore must have a plan number. What plan number should CONEXIS assign to this plan? Please be sure that the number you provide is not already assigned to another plan sponsored by this company. Under a cafeteria plan, certain benefits may be paid for on a pre-tax basis. Please choose the benefits you would like to offer on a pre-tax basis through your plan: Health Insurance Dental Insurance Vision Insurance Group-Term Life Disability HSA Other (specify) What kind of account will be used to pay claims for this plan? Number of days an employee has to provide notification of a Qualified Life Status Change General Assets Trust Account Cafeteria plans typically offer a run-out period, which is a specified period that immediately follows the end of the plan year. During this period, plan participants can submit claims that they incurred during the plan year. Would you like to offer a run-out period? If yes, how long is the run out period for this plan? Defaulted to 90 days unless otherwise stated If you choose to offer a run-out period, you may also choose how that run-out period applies to terminated employees. The run-out period for terminated employees can be measured from the date of termination or the end of the plan year. Please indicate your choice below: days Date of termination End of the plan year Do you sponsor an HSA that is available to individuals who are eligible for your FSA plan? Does your FSA plan offer a limited reimbursement option? Section B Plan Options Regulations allow an employer to reimburse dependent care expenses incurred after employment ends (often referred to as a spend down feature). Do you want to offer this feature as part of your plan? Do you wish to offer the 2 month 15 day Grace Period Extension (additional fees apply)? If yes, please indicate the plan(s) you would like to include this feature: Health FSA Dependent Care FSA You may choose between a liberal or conservative approach for handling life status changes experienced by your plan participants. Please indicate your preferred approach below: Liberal. Accepts claims submitted either before or after the election change to be applied to the new election amount Conservative. Does not allow a claim to be reimbursed out of the new election amount if the date of service is prior to the election change. PLEASE COMPLETE SECTIONS C, D, and E ON THE NEXT PAGE

4 Cafeteria Plan Information Form Section C Flexible Spending Account Information Health FSA Dependent Care FSA Minimum Contribution Amount Maximum Contribution Amount Minimum Contribution Amount Maximum Contribution Amount Eligibility Waiting Period (participation begins on): Date of Hire First of the Plan Year, or First of the Month following (number of) Days Months Other (specify) Who is eligible to participate? Full-time Employees Part-time Employees All Minimum hours worked required to be eligible: Section D Contribution Information Contributions to the plan will be made by: Employee Only Employer Only Employee and Employer If Employer Contributions are applicable, they are made for: $5, Eligibility Waiting Period (participation begins on): Date of Hire First of the Plan Year, or First of the Month following (number of) Days Months Other (specify) Who is eligible to participate? Full-time Employees Part-time Employees All Minimum hours worked required to be eligible: If Employer Contributions are applicable, they are made: At the beginning of the Plan Year Pro rata each pay period If Employer Contributions are applicable, the amount per participant is: Health FSA Dependent Care FSA for Health FSA for Dependent Care FSA Section E Payroll Information All fields in this section are required. The information provided in this section will be used to set up your payroll and pay date information in the CONEXIS system. We use this information to post deductions to your participants accounts, which in turn drives the payment of their claims. As an alternative, you may provide a copy of your payroll schedule(s). IMPORTANT: All pay dates must fall within the plan year of your plan. Payroll frequency #1 (Check One) Weekly Bi-weekly Monthly Semi-Monthly Start Date of first Pay Period End Date of first Pay Period First Pay Date of Plan Year Last Pay Date of Plan Year Pay period start and end dates for last pay date of the plan year Are any pay periods skipped for any reason? Start Date: End Date: If so, which pay periods are skipped? (separate dates by a semi-colon) Payroll frequency #2 (Check One) Weekly Bi-weekly Monthly Semi-Monthly Start Date of first Pay Period End Date of first Pay Period First Pay Date of Plan Year Last Pay Date of Plan Year Pay period start and end dates for last pay date of the plan year Are any pay periods skipped for any reason? Start Date: End Date: If so, which pay periods are skipped? (separate dates by a semi-colon) How will the employer notify CONEXIS of payroll deductions? File Transfer Employer will enter via CONEXIS Web site Assumed (CONEXIS posts deductions automatically according to payroll schedule(s) above) If the chosen payroll deduction method is Assumed, CONEXIS will a deduction report for review. Please provide the address for the individual that should receive a copy of this report (separate multiple addresses by a semi-colon). IMPORTANT: Because of the information contained within the deduction report, all individuals receiving deduction reports must be HIPAA authorized PLEASE COMPLETE SECTIONS F and G ON THE NEXT PAGE

5 Cafeteria Plan Information Form Section F Claims Payment Options CONEXIS issues reimbursements on a weekly basis. Please choose the day of the week you would like to have reimbursements issued: Monday Tuesday Wednesday Thursday Friday CONEXIS will a funding report to the employer one business day prior to each reimbursement date. Please provide the address for the individuals that should receive a copy of this (separate multiple addresses by a semi-colon) and choose your preferred format. IMPORTANT: Because of the information contained within the funding report, all individuals receiving funding reports must be HIPAA authorized PDF Spreadsheet Section G Employer Representative This form was completed by: Name Title Phone Number

6 Division Contact Information Instructions: Complete this form only if your company has multiple divisions or classes that need to be listed separately in the CONEXIS system. For this purpose, class means a class of employees, such as part-time or union employees, while division refers to a separate location, division or area. When completing this form, all fields are required. Please complete additional copies of this form as necessary. IMPORTANT: If you choose to grant Web site access to the contact listed, CONEXIS will assume that the contact is authorized by the employer to receive PHI from CONEXIS. Do not provide contact information for any individuals that are not authorized to receive PHI from CONEXIS. Division/Class #1 Is this a Division or a Class? Division/Class Name Division Class Contact Name Phone Number Fax Number Address What level of Web site access should CONEXIS grant to this individual? If granting Web site access, should that access be limited to this division/class only? If you choose no, contact will be given access to all divisions/classes. Read-Only Full ne Should this division/class receive its own separate reports (i.e., reports that contain information regarding employees from this division or class only? Does this division/class require a separate bank account to pay claims and card transactions? If yes, you must complete a separate CONEXIS Banking Set-Up and ACH Authorization Form and UMB ACH Authorization Form for this division. Should this division/class receive a separate bill for CONEXIS services? If yes, CONEXIS will a funding report to the appropriate contact one business day prior to each reimbursement date. Please provide the address for the individuals that should receive a copy of this (separate multiple addresses by a semi-colon) and choose your preferred format. IMPORTANT: Because of the information contained within the funding report, all individuals receiving funding reports must be HIPAA authorized PDF Spreadsheet Division/Class #2 Is this a Division or a Class? Division/Class Name Division Class Contact Name Phone Number Fax Number Address What level of Web site access should CONEXIS grant to this individual? If granting Web site access, should that access be limited to this division/class only? If you choose no, contact will be given access to all divisions/classes. Read-Only Full ne Should this division/class receive its own separate reports (i.e., reports that contain information regarding employees from this division or class only? Does this division/class require a separate bank account to pay claims and card transactions? If yes, you must complete a separate CONEXIS Banking Set-Up and ACH Authorization Form and UMB ACH Authorization Form for this division. Should this division/class receive a separate bill for CONEXIS services? If yes, CONEXIS will a funding report to the appropriate contact one business day prior to each reimbursement date. Please provide the address for the individuals that should receive a copy of this (separate multiple addresses by a semi-colon) and choose your preferred format. IMPORTANT: Because of the information contained within the funding report, all individuals receiving funding reports must be HIPAA authorized PDF Spreadsheet Employer Representative Form completed by: Name Title Phone Number