THE ALLIANCE HEALTH PLAN New Employer Checklist OPEN ENROLLMENT 2017 Open Enrollment is November 14 December 9 This checklist is for employers who wish to enroll their employees in The Alliance Health Plan (all forms are located at www.alliancebenefits.org) Forms To Complete: Employer Bank Authorization Form Employer Certification Form (one per employee) Employee Enrollment Form (one per employee) Questions? Please call or email: (800) 700-2651 benefits@cmalliance.org Fax all completed and signed forms to Alliance Benefits at (719) 262-5397
Employer Bank Authorization Form To be completed by employer Due By Dec 9 EMPLOYER BANK INFORMATION Employer s Bank Name: Bank Phone Number: Bank City: Bank State: Bank Zip Code: Routing Number (9 digits): Account Number: Select only one: checking account savings account EMPLOYER AUTHORIZATION FOR AUTOMATIC PAYMENT I hereby authorize THE CHRISTIAN AND MISSIONARY ALLIANCE to withdraw funds each month from this account for payment of insurance premiums and HSA contribution elections. Premiums will be withdrawn by the third business day of each month for that month s coverage. I understand this authority is to remain in full force and effect until ALLIANCE BENEFITS has received written notification from the employer authorized representative of its termination or change in such manner as to afford THE CHRISTIAN AND MISSIONARY ALLIANCE and employer s bank reasonable opportunity to act on termination or change request. Church Code: Name of account holder as printed on check: Authorized Employer s Signature: Date: Title: Contact phone: E-mail: Please complete, sign, and fax this form to (719) 262-5397 For questions call (800) 700-2651 or email benefits@cmalliance.org ALLIANCE BENEFITS OFFICE USE ONLY Startup Request Change Request Effective Date: Page 1 Revised 11/16
Employer Certification Form To be completed by employer Due By Dec 9 EMPLOYER INFORMATION Employer Name: Church code: Telephone number: Fax number: Employer Tax ID number (EIN): (Required - same # used for employer tax filing) Employer s physical address: Billing address (if different): For Medicare reporting, please indicate the number of full-time and part-time employees you currently have on payroll: 1 19 Employees 20 99 Employees More than 100 employees According to the Patient Protection and Affordability Act we are required to know how much the employee is required to pay for their insurance premiums. If the amounts listed below change, you are required to inform Alliance Benefits. Employee pays percentage of premiums % employee % employer EMPLOYER ELIGIBLITY COMPLIANCE (REQUIRED) Please verify that 100% of all Licensed Official Workers on staff are enrolled in The Alliance Health Plan with the exception of being covered under a Spouse s Employer Plan, Medicare/Medicaid, a Bi-Vocational Employer Plan: Yes No NOTE: This exception does not include a Licensed Official Worker who is enrolled in a ministry cost-sharing program or the government exchange program. EMPLOYEE REASON FOR ENROLLING AND VERIFICATION Employee Name: Last First: MI: New Hire Enrollment New Church to Plan Employment Transfer Rehire/Reinstatement Loss of Coverage Open Enrollment Other (please describe) Qualifying effective date (required): Total annual salary (needed for life and disability insurance): Employee s Title: HSA AUTHORIZATION FOR CONTRIBUTION AGREEMENT EMPLOYER MONTLY HSA (Included in monthly premium) Select box that applies to this employee $84/Employee only $167/Employee + Child(ren) EMPLOYER ADDITIONAL MONTHLY HSA EMPLOYEE ADDITIONAL MONTHLY HSA $167/Employee + Spouse $167/Family $ $ $ TOTAL MONTHLY HSA AMOUNT For 2017, the IRS allows an individual to contribute up to $3,400 and a family may contribute up to $6,750. These limits include the combined total of employer and employee contributions. Employees who are age 55 or older are allowed to contribute an additional $1,000 in catch-up contributions. Any remaining balance in the employee s HSA will rollover and accumulate year to year. Page 1 Revised 11/16
HSA AUTHORIZATION FOR CONTRIBUTION AGREEMENT (CONTINUED) I understand that employees are not eligible to participate in an HSA if: They are enrolled in Medicare, Tricare, or a Veteran s plan They are enrolled in additional coverage that is not a High Deductible Health Plan (HDHP) They are claimed as a dependent on another person s taxes I hereby authorize ALLIANCE BENEFITS to withdraw funds for the above HSA employee contribution listed. I understand HSA employee contributions are included in the health plan insurance premium and will be billed at the same time. After the billing is collected, HSA funds will be deposited into the employee s account by the 10 th of every month. Changes (including termination of employment) to contributions must be submitted to Alliance Benefits by the 25 th of the month to be included in the following month s billing. HSA contributions cannot be refunded once collected. All HSA employer and employee contributions must be reported on employee s W-2, Box 12, Code W. I have read the above HSA Authorization for Contribution section of this form and agree that it is the participant s responsibility to be in compliance with IRS rules regarding their HSA. Alliance Benefits is not responsible for an ineligible employee participating in an HSA. Alliance Benefits must be notified if an employee is ineligible. Tax penalties may be incurred by the employee if the annual maximum contribution amounts are exceeded. EMPLOYER AUTHORIZATION SIGNATURE (REQUIRED) The undersigned employer representative confirms that this applicant is a paid employee of the above named organization, working 20 or more hours per week, and that the reported salary is accurate. We understand the Health Plan coverage being requested by this applicant, upon approval, will be added to our employer s monthly billing statement. (The employer representative cannot be the applicant.) Authorized Employer s Printed Name: Authorized Employer s Signature: Date: Title: Contact phone: E-mail: Please complete, sign and fax this form to (719) 262-5397 For questions call (800) 700-2651 or email benefits@cmalliance.org A confirmation email will be sent to the employee and employer once paperwork is processed Page 2 Revised 11/16
Due By Dec 9 Health Plan Employee Enrollment Form The employee enrolling in the plan must be actively working and paid for working 20 hours or more per week. With the exception of address updates, all changes must be made within 30 days from the qualifying date to enroll or they are subject to at least a sixty day waiting period. New enrollment effective date is the first day of the month following the qualifying event date. If the event date falls on the first day of the month, coverage will begin on this day. REASON FOR ENROLLING (REQUIRED) New Hire Enrollment New Church to Plan Employment Transfer Rehire/Reinstatement Loss of Coverage Open Enrollment Other (please describe) Qualifying effective date (required): GENERAL INFORMATION (REQUIRED) Name of Employer Location or Church Code Employee Name: Last First MI Birth Date Social Security Number Home Phone Work Phone Cell Phone Home Address City State Zip Code County E-mail Gender: Male Female Marital Status: Single Married US Citizen/Citizen Resident: Yes No BENEFIT ELECTION (REQUIRED) Medical Benefits: Employee Only Employee + Spouse Employee + Child(ren) Family Coverage Type: The Alliance HDHP Premium Plan (Medical, HSA, Prescription, Dental, Vision, $30k Life Insurance, Long Term Disability) The Alliance HDHP Standard Plan (Medical, HSA, Prescription, $30k Life Insurance) DEPENDENT INFORMATION (LIST SPOUSE AND/OR CHILDREN TO BE COVERED) Eligible children are those under age 26 Last Name First Name MI Social Security # (Required) Birth Date Gender (Circle) Relationship Disabled (Circle) Are you or any of your dependents (including spouse) covered under another health plan or Medicare? Yes No If yes, please list coverage details: Page 1 Revised 11/16
BENEFICIARY DESIGNEE FOR BASIC LIFE INSURANCE (REQUIRED) $30k of Basic Life Insurance is automatically included in your health plan package. Please designate beneficiaries below: Primary Beneficiary Name(s) Address % Social Security # Birth Date Relationship Secondary Beneficiary Name(s) Address % Social Security # Birth Date Relationship VOLUNTARY LIFE INSURANCE Additional life insurance coverage may be purchased for employee, spouse and children (up to age 23) who are enrolled in the health plan package. Refer to the Summary Guide (pg 10) on the Alliance Benefits website www.alliancebenefits.org for requirements and rates. Employee voluntary life: Yes No Spouse voluntary life: Yes No Child voluntary life: Yes No If yes, volume amount $ If yes, volume amount $ If yes, volume amount $ HSA ACCOUNT SET-UP Once enrolled, you will automatically be set up with a health savings account (HSA) to receive the employer contributions included in the monthly premium. More details will be sent regarding your account set up at the time your enrollment has been processed. If you wish to contribute additional funds to your HSA, please work with your employer to include this amount on the Employer Certification Form. The following are ineligible to participate in an HSA: Those enrolled in Medicare, Tricare, or a Veteran s plan Those enrolled in additional coverage that is not a High Deductible Health Plan (HDHP) Those who can be claimed as a dependent on another person s taxes For 2017, the IRS allows an individual to contribute up to $3,400 and a family may contribute up to $6,750. These limits include the combined total of employer and employee contributions. Employees who are age 55 or older are allowed to contribute an additional $1,000 in catch-up contributions. Any remaining balance in the employee s HSA will rollover and accumulate year to year. I have read the above HSA section of this form and agree that it is my responsibility to be in compliance with IRS rules regarding my HSA. Alliance Benefits is not responsible for an ineligible employee participating in an HSA. Alliance Benefits must be notified if you are ineligible. Tax penalties may apply if the annual maximum contribution amounts are exceeded. REQUIRED SIGNATURE By signing, I authorize to be covered under the terms of the plan I have chosen. Employee s Signature: Date: Please complete, sign and fax this form to (719) 262-5397 Questions: (800) 700-2651 or benefits@cmalliance.org A confirmation email will be sent to the employee and employer once enrollment is confirmed ALLIANCE BENEFITS OFFICE USE ONLY PLAN ADMINISTRATOR GROUP NUMBER PLAN TYPE EFFECTIVE DATE LOCATION CODE THE ALLIANCE J45 Premium Standard Page 2 Revised 11/16