Full legal name of the Employer: Effective : Section 125/FSA Set-up Form Plan Year: Begins (mm/dd): Ends (mm/dd): Is first year a short Plan Year? Yes No If yes, please provide: Start : End : Do you currently have an FSA in place with another vendor? Yes No If yes, will any of the following apply during the set-up process? Will ASi administer the run-out of your current plan? Yes No Does your current plan allow for a $500 Rollover or 2 ½ month Grace Period? ( Please circle one) Is the Employer a member of the one of the following groups? Affiliated Service Group Controlled Group If yes, please list all members of the group: Plan Number: 501 502 503 504 505 506 Pay Periods (if none selected, one will be assigned) Weekly Bi Weekly Semi Monthly Monthly Plan Start Plan End First Payroll Last Payroll # of Payrolls per plan Year Plan Benefits The employer is offering the following benefits under this plan (check all that apply): Premium Only Plan Medical FSA Benefits Dependent Care Benefits Limited FSA Benefits (HSA Compatible) Employer Funded FSA Simple FSA Please indicate which Premium Only Plan Benefits will be offered pretax (check all that apply): Medical Insurance Dental Insurance Vision Insurance Disability Insurance Group Term Life Insurance HSA Contributions* Other: (Specify) *If offering an HSA program, medical FSA expenses will be limited for those participating in the HSA to qualified dental, vision and OTC expenses. ASi will need to be made aware of the employees enrolled in the HSA. Members enrolled in any of the above contracted benefits will automatically be enrolled in the Premium Only Plan. 01/2016 Page 1 of 4
Please select from one of the below options: (For more details on our funding options, please refer to our Funding Guide) Debit Card on Group Banking Medical Component Dependent Care Component * Please complete the Bancorp ACH form (this is the account that will be linked to the debit cards). * Please complete the ASi ACH form for manual claims that may be submitted. * Debit cards with the medical component require a 5% deposit of the aggregate participant annual election amount. Deposit must be received prior to debit cards being issued. *Debit card security deposit will be refunded after 120 days of the Plan termination Debit Card on ASi Banking (Additional fees may apply) Medical Component Dependent Care Component * Please complete the ASi ACH form to receive contributions. * Debit cards with the medical component require a 10% deposit of the aggregate participant annual election amount. Deposit must be received prior to debit cards being issued. *Debit card security deposit will be refunded after 120 days of the Plan termination. Non-Debit Card Funding (Choose one of the following) ACH for Claims (Debits your account for claim utilization on a weekly basis, as applicable. ACH authorization form must be completed.) ACH for Contributions (Debits your account for contribution each applicable pay period. ACH authorization form must be completed.) Mail for Contributions (Client to mail contribution check to ASi each pay period.) Plan Eligibility The same day employee becomes eligible for contract(s), as described under Plan Benefits. Other: Minimum service requirement for an Eligible Employee to become eligible to be a Participant in the Plan: i. None. ii. Completion of hours of service. iii. Completion of days of service. iv. Completion of months of service. v. Completion of years of service. Please indicate if any of the following employee classifications are going to be excluded from enrolling in the plan: There are no exclusions; or The following classes of employees are excluded (check all that apply): Employees covered under a collective bargaining agreement (Union) Leased employees Nonresident aliens Part-time employees (If checked, a part-time employee is an employee who works less than hours per week. Other (specify): 01/2016 Page 2 of 4
Medical FSA Component The minimum annual benefit amount that a participant may elect to receive for medical care expenses incurred in any plan year shall be: (If left blank, the minimum will default to zero) (Choose one of the below options) The maximum annual benefit amount that a participant may elect to receive for medical care expenses incurred in any plan year shall be: ($2,550 Maximum) The maximum election amount allowed pursuant to IRS regulations. (Which may be updated annually.) Coverage for a participant who enters the Plan mid-year: Will be allowed to elect the entire maximum annual benefit amount; or Will be allowed to elect a pro-rated benefit amount based on the total months remaining in the Plan year. A participant who has elected to receive Medical FSA benefits for a plan year, may request reimbursement from the administrator no later than: 60 or 90 days following the earlier of (a) the close of the plan year in which the expense was incurred or (b) the date of the employee s termination. Would you like to allow one of the following: (a) a grace period of 2 ½ months for the medical component? Yes No (b) a rollover (up to $500 per plan year) Yes $ No Dependent Care Component The maximum annual benefit amount that a participant may elect to receive for dependent care expenses incurred in any plan year shall be $2500 if the employee is married but filing separately and $5000 if the employee is married and filing a joint return or is a single parent. A participant who has elected to receive Dependent Care benefits for a plan year, may request reimbursement from the administrator no later than: 60 or 90 days following the earlier of (a) the close of the plan year in which the expense was incurred or (b) the date of the employee s termination. Is this Plan subject to FMLA? No (1-49 employees) Yes (50+ employees) 01/2016 Page 3 of 4
Listed below are the options on how your members will receive their quarterly statements. Please select from one of the below options: Employees will receive their statements via e-mail. (No Charge) All employees statements will be emailed to the employer to be printed and distributed. (No Charge) ASi Will print the statements and send them to the employer for distribution. (Additional fees will apply) ASi will print and mail statements to the member. (Additional fees will apply) No statements provided Employees will access their accounts online. (No Charge) Please select from one of the following options on how your company would prefer to receive the monthly invoices for administrative fees: U.S. Mail E-Mail Please provide the e-mail address if different than what is listed on the application: Related Employers That Have Adopted This Plan: Please list full legal name for any employers adopting this Plan: Certification of Accuracy I, certify that the information provided on this form is accurate to the best of my knowledge. I understand that ASi will utilize this information for preparation of our Plan Documents. Signature Title ASi Internal Use Only: Administration Fees: Implementation Fees: Per Participant/Per Month: Debit Card Security Deposit: Annual Fee: 01/2016 Employee Statements: Other: Page 4 of 4
ASi s Funding Guide Debit Card Funding: Employers have the option to offer employees pre-loaded debit cards to pay for out-of-pocket expenses that are eligible under the IRS guidelines. Debit cards are available for both the medical and/or dependent care components under the FSA. ASi offers two different banking options to utilize debit card funding: Option 1 Client Banking Client will retain the employees pre-tax deductions in their own banking account. Client will complete the Bancorp ACH Authorization form with the account information that will be linked to the debit cards for funding. Bancorp is the debit card vendor and will ACH for utilization on a weekly basis for the previous week s debit card usage. You will receive a report every Monday detailing the total amount that will be deducted from your account. In the event that the employee is unable to use the debit card, the employee is able to submit a claim to ASi for reimbursement. They will either receive a check or direct deposit. Client will sign up for ASi ACH claim utilization payments. ASi will invoice the client, weekly or monthly (depending on the volume of claim utilization), for the payment of the manual claims that are processed. Debit Card will require a 5% security deposit of the aggregate participant annual election amount. Option 2 ASi Banking Client will send the employees contributions directly to ASi on a per pay period basis. Client has the ability to sign up for ACH to send contributions. In which case, ASi will pull from client s account the necessary per pay period deductions. Debit Cards on ASi banking will require a 10% Deposit. Things to Remember *Debit Cards cannot be ordered until security deposit is received. *The security deposit will be refunded after 120 day of the Plan termination. * Clients will be notified of all ACH transactions 24 hours prior to the transaction taking place. NON - Debit Card Funding: Employees submit claims to ASi for each reimbursement request. Option 1 ACH for Claims Client will complete an ASi ACH authorization form for the account in which the contributions will be held. ASi will debit the client s account for claim utilization on a weekly basis, as applicable. Option 2 ACH for Contributions ASi will debit the client s account for employee contributions each applicable pay period. Client will complete an ACH authorization form linked to the account in which the contributions will be held. Option 3 Mail Contributions Client will mail contributions to ASi total for the of all per pay period pre-tax deduction in one contribution check. Client will also send a deduction to report along with the contribution check.
The Bancorp Bank Payment Solutions Group AUTHORIZATION FOR ACH DEBITS / CREDITS Depositor Name as Shown on Bank Records Checking Account Number/ Transit Routing Number (A voided check or spec sheet must be attached for this account) TO: (Bank Address: Street, Box #, City, State and Zip Code) Depositor authorizes The Bancorp Bank to present automated debits and credits to and from the above listed account as required to perform their responsibilities related to processing Depositor s benefit program. This authorization will remain in effect until revoked by Depositor in writing and until you actually receive such notice Depositor agrees that you shall be fully protected in honoring any such ACH transaction. Depositor agrees that your treatment of each such ACH transaction and your rights in respect to it shall be the same as if it were a check signed by Depositor. I authorize payments to be withdrawn daily or weekly as needed. d this day of, 20. Signature of Depositor in Agreement with Bank Records Please update your ACH filter (on the above reference account) to grant access to The Bancorp Bank. The Bancorp Bank identification number is: 1050006509.
ADMINISTRATIVE SOLUTIONS, INC. HRA/FSA Authorization for Electronic Funds Transfer Company Name: _ EFT Contact Name: Please debit my account for: gfedc Contributions gfedc Fees I hereby authorize Administrative Solutions, Inc. to initiate variable debit entries to my checking account or savings account indicated below and my financial institution named below to debit the same to such account. Account Number: Financial Institution Branch: City: State : Bank Routing Number This authority will remain in full force and effect until Administrative Solutions, Inc. has received written notification from me of its termination in such time and in such manner as to afford Administrative Solutions, Inc. a reasonable opportunity to act on it. Signature **An actual voided check must be attached** Staple voided check here If an actual check is not available to attach (i.e. some savings accounts), you are responsible for obtaining the correct routing number from your financial institution. Fax or mail to: Administrative Solutions, Inc. PO Box 5809 Fresno, CA 93755 Fax: (559 256-1321 S:\Advisor's Assistant\HRA Proposal-Applications\ACHEFTForm.doc