ERISAExpress Form

Wrap - Employer Affiliates

An affiliate generally means:
- Subsidiaries which are owned (at least 80% ownership) by the plan sponsor
- Other companies which are owned (at least 80% ownership) by a parent company which also owns 80% of the plan
Does this employer have any affiliates?

YesNo
Does the affiliate have a different Tax ID than the employer's Tax ID?

YesNo
Affiliate Name
(Legal name of Company)
Affiliate Federal Tax ID
Affiliate Address

Street Address

Street Address Line 2

CityState

Zip Code

Wrap - Plan Information
Is this Plan new or a restatement?
Plan Year Start

MonthDayYear
Date
Plan Year End

MonthDayYear
Date
Original Effective Date

MonthDayYear
Date
Amended and Restated Date

MonthDayYear
Date
Is this entity subject to Section 1557 of the Affordable Care Act?
Civil Rights Coordinator Name
Civil Rights Coordinator Name
Civil Rights Coordinator Email
example@example.com
Civil Rights Coordinator Email
example@example.com
Civil Rights Phone Number
Please enter a valid phone number.
Are claims administration/appeals procedures included in each of the underlying certificates or benefit policies?
(The claims administration/appeals procedures stated within any benefit policy/certificate covered by this Wrap Plan will govern the claims procedures for that specific policy/certificate.)

Wrap - Employee Eligibility
Include Employees that Work More Thanhours Hours Per Week..
* Full-time and salaried employees are already included
Exclude the following Employee Classes (Check all that apply)

UnionSalaried EmployeesLeased EmployeesNon-Resident AliensHourly EmployeesOther
Add Other Exclusion
Entry Into Plan
(The eligibility requirements stated within any benefitpolicy/certificate covered by this Plan will governeligibility for that specific policy/certificate.)
Plan entry was "Other". Please specify below entry requirements.
Do you have variable hour employees?
Will you be using the IRS Look-back measurement method to determine employee status?

Wrap - Benefit Contribution Information
How Are Employee Contributions Made?
Please specify "Other" contributions below
Contribution Sources

EmployeesEmployers
Include Subrogation provision in this document?
Include FMLA provision in this document?
Include COBRA provision in this document?
Do you have any Medicare Eligible participants (active, retired, COBRA, or Disabled), or any of their dependents, enrolled in your group health plan or prescription drug plan?
If your Group Health Plan or Rx Benefit is "Creditable" with Medicare, which notices are to be included in the document?

Wrap - HIPAA Benefits
HIPAA Designated Employees

Please list the titles of all employees or classes of employees (or others under the control of the Plan Sponsor) who receive or use Protected Health Information (PHI) in connection with the Plan Administration in the normal course of Plan operations.
Please List the Job Titles of Your HIPAA-Designated Employees
Include HIPAA provision in this document?
Are the benefits included in this plan self-funded or fully-insured?
Would you like all language referring to "self-funded plans" to be removed