Employer Enrollment Application
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Plan Administrator
Please enter the Authorized Managing Representative of the Organization (Corporate Secretary, President, Partner, Owner, etc.):
First Name
*
Last Name
*
Email
*
Phone
*
Fax Number
STOP AND READ THIS FIRST!
Employer Information for Plan Documents
Enter the legal name of the Employer EXACTLY as you would like to see it in your plan documents. Do not type all in upper case or all in lower case; check your spelling and punctuation. If using a DBA, or the legal name includes a DBA, please include in the Notes the full legal name and which name you would like us to use as the common name in the documents. Please enter the physical address of the Employer. If you have a P.O. Box or alternate address that you would like the document mailed to, this may be entered in the Notes or on the payment form.
Employer
*
Address
*
City
*
State
*
Postal code
*
Captcha
Please Provide the Form of business, State of Incorporation, and FEIN (Must be nine digits. This is NOT the owner's SSN unless the business is a Sole Proprietorship.)
Form of Business
*
S Corporation
C Corporation
Partnership
Sole Proprietorship
LLC
Non Profit
Government
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State of Incorporation
*
State of Incorporation
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Employer Federal ID#
*
If another company is owned by this Employer, and you wish to include the other company's employees in this benefit, add it as an Affiliate Company. Please input the legal name exactly as you would like it to appear in the documents along with their FEIN.
Affiliate Companies
Type of Plan
*
New Plan
Amended Plan
If you began giving this benefit to your Employees more than three months ago and are wishing to make changes, chose an "Amended Plan". Otherwise, choose "New Plan".
In most cases, the Plan Year will be January 1 through December 31. If you are starting mid-year, your first Plan Year will be a short Plan Year.
Short Plan Year effective dates must be 60 days in the future from signatory date and on the 1st of the month.
New Plan Effective Date
*
Amended Plan effective dates must be 60 days in the future from signatory date and on the 1st of the month.
Effective Date of Amended Plan
*
Please name the person inside your company who will be responsible for the proper handling of medical information protected under HIPAA law:
PHI Person
*
Will your plan offer different Benefits Amounts by
Employee Classes?
*
Will you offer different Benefit Amounts by Employee Class?
Yes
No
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Please enter the MONTHLY benefit limits for each employee.
Employee Benefit Amount
*
$
Eligibility requirements: (Who is Eligible?)
All employees regularly scheduled to work ____ or more hours per week. (Minimum = 1 Maximum = 40)
Hours Per Week
Waiting Period:
Please enter the required number of days of employment before employee eligibility. Minimum = 0 (First day of Employment). Maximum = 90. Typical = 30, 60 or 90.
Employees are eligible the first day of the month coinciding with or next following ____ consecutive days of employment:
Number of Days
Please provide us with your proposed Class structure.
Employee Classes File
Upload here
Each class must include four things: 1. CLASS NAME, 2. BENEFIT LIMIT, 3. MINIMUM HOURS PER WEEK, and 4. WAITING PERIOD for new employees to be eligible.
* If you need more time or help deciding on Employee Class benefits, this information can be submitted at a later date.
Upload or email it to support@benefitx.com.
Number of Employees
*
Please provide us with a spreadsheet of all W-2 employees. include each employee's Legal Name, Email Address, Hire Date. (and Employee Class to which you wish them assigned, if applicable)
Employee List
Please provide us with a spreadsheet of all W-2 employees. We need their Legal Name, Email, Employee Class, and Hire Date.
Upload or email it to support@benefitx.com.
Plan Design Notes Box
Benefit X-Change fees
I (We) authorize the Benefit X-Change to initiate debit entries to my (our) account with the depository named below. If the Benefit X-Change erroneously debited funds from my (our) account, I (we) authorize the Benefit X-Change to initiate the necessary credit entries not to exceed the total of the original amount debited for the entry in question.
Bank Account Information
Financial Institution Name
*
(Routing number is exactly nine digits)
Routing Number
*
Bank Account Number
*
This authorization will remain in effect until the Benefit X-Change has been notified by me that it is to be terminated. To discontinue automatic draft, customer must notify the Benefit X-Change at least 20 days before the next draft date.
Account Address
Account City, State
Account Zip
*
Signature
*
Clear
Signatory Name
*
Signatory Date
*
Voided Check
PLEASE ATTACH VOIDED CHECK HERE
Upload or email it to support@benefitx.com.
