Benefit Authorization (Broker)
To be completed by Broker
Section 1: Company Information
Company Name
*
Doing business as (DBA) name
Leave blank if not applicable
Tax ID (EIN)
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Address different than mailing address?
*
Yes
No
Billing Address
Street Address
Street Address Line 2
City
State
Zip Code
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Section 2: Company Contacts
Only the below listed individuals will be authorized to communicate with our Employer Services team.
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Contact Type (Select All that Apply)
*
Primary Contact
Billing Contact - Receives claims funding requests and is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Eligibility - Receives eligibility transaction communications and the monthly premium bill statement.
HIPAA Officer - Receives access to detailed personal health information.
Contract Signer - This person is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Other
Additional Contacts
*
Yes
No
Selecting this option creates more contact fields
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Contact Type (Select All that Apply)
Primary Contact
Billing Contact - Receives claims funding requests and is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Eligibility - Receives eligibility transaction communications and the monthly premium bill statement.
HIPAA Officer - Receives access to detailed personal health information.
Contract Signer - This person is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Other
Additional Contacts
Yes
No
Selecting this option creates more contact fields
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Contact Type (Select All that Apply)
Primary Contact
Billing Contact - Receives claims funding requests and is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Eligibility - Receives eligibility transaction communications and the monthly premium bill statement.
HIPAA Officer - Receives access to detailed personal health information.
Contract Signer - This person is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Other
Additional Contacts
Yes
No
Selecting this option creates more contact fields
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Contact Type (Select All that Apply)
Primary Contact
Billing Contact - Receives claims funding requests and is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Eligibility - Receives eligibility transaction communications and the monthly premium bill statement.
HIPAA Officer - Receives access to detailed personal health information.
Contract Signer - This person is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Other
Additional Contacts
Yes
No
Selecting this option creates more contact fields
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Contact Type (Select All that Apply)
Primary Contact
Billing Contact - Receives claims funding requests and is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Eligibility - Receives eligibility transaction communications and the monthly premium bill statement.
HIPAA Officer - Receives access to detailed personal health information.
Contract Signer - This person is listed as the Plan Administrator in the Plan Document / Summary Plan Description.
Other
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Section 3: Funding and Payroll
The below information is to confirm when the deductible resets, when the client plan renews and when EBA&M eff date is. These all 3 can be the same or different.
EBA&M Effective Date
*
/
Month
/
Day
Year
Date
HRA Plan Year Start Date
*
/
Month
/
Day
Year
Date
Base plan carrier renewal date
*
/
Month
/
Day
Year
Date
Separate divisions for billing and reporting purposes?
*
Yes
No
If you would like to add divisions to separate your employees for reporting purposes, please input them here:
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Section 4: Health Reimbursement Arrangements (HRAs)
Only complete if offering a Health Reimbursement Arrangement.
Type of HRA offered
*
HRA Debit Card w/Cloud Platform
Reimbursement only w/Cloud Platform
Claims processing w/Dual ID card process
Other
Type of expenses eligible under the HRA plan
*
General purpose health eligible expense (213 (d) expenses list)
Limited purpose eligible expense (Chiro, Dental, Vision, Mental Health)
Limited purpose HRA, select all that apply:
Dental
Vision
Chiropractic
Mental Health
Other
How will the HRA funds be available to participants?
*
100% at the beginning of plan year or upon eligibility
1st of each month (1/12)
Per Payroll Frequency
Quarterly
Other
4th Line Embossing
Limited to 19 characters
Does HRA offer run-in?
*
Yes
No
Run In Effective Date
-
Month
-
Day
Year
Date
Run-Out Period:
*
(Please indicate how many days employees will have to file claims after the plan year end date.)
Card Delivery Method:
Employer
Employee
Other
Upload Sold Quote / Takeover TPA Renewal
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of
HRA Benefits
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of
Base Plan Summary
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Base Plan SBC
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Plan 1 Insurance Carrier:
How much does the employer contribute to the HRA annually?
Contribution Amount
Single
Single + Spouse
Single + Dependent
Single + Family
Chiropractic benefit covered?
*
Yes
No
Prescription benefit covered?
*
Yes
No
Additional Plans?
*
Yes
No
Plan 2 Insurance Carrier:
How much does the employer contribute to the HRA annually?
Contribution Amount
Single
Single + Spouse
Single + Dependent
Single + Family
Chiropractic benefit covered?
Yes
No
Prescription benefit covered?
Yes
No
Additional Plans?
Yes
No
Plan 3 Insurance Carrier:
How much does the employer contribute to the HRA annually?
Contribution Amount
Single
Single + Spouse
Single + Dependent
Single + Family
Chiropractic benefit covered?
Yes
No
Prescription benefit covered?
Yes
No
Spanish benefit summary?
*
Yes
No
EOB Concierge
*
Yes
No
N/A on EBA&M Cloud
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Section 5: Flexible Spending Accounts (FSAs)
Only complete if offering Flexible Spending Accounts through the EBA&M Cloud.
Does client offer FSA?
*
Yes
No
Type of FSA(s) offered:
Healthcare FSA
Dependent Care FSA
Transit FSA
Other
Rounding of Payroll Deductions:
Round Up, Adjust First Pay Period
Round Up, Adjust Last Pay Period
Round Down, Adjust First Pay Period
Round Down, Adjust Last Pay Period
Round Down, Do Not Adjust
Payroll Cycle:
Weekly (52 pay periods/year)
Bi-Weekly (24 pay periods/year)
Bi-Weekly (26 pay periods/year)
Semi-Monthly
Monthly
Please complete the specific payroll dates in the chart below:
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
1st
2nd
3rd
4th
5th
Complete for each FSA offered:
Employee Maximum Annual Contribution
Employee Minimum Contribution
Employer Annual Contribution
Medical FSA
Dependent Care FSA
Limited Purpose FSA
Limited Purpose FSA
Run Out Period:
days following the Plan Year End Date
Grace Period: (Allow an extension of the plan year end date in order for participants to incur services. Grace Period extension is defined as two full months)
Medical FSA
Dependent Care FSA
Limited Purpose FSA
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Section 6: Qualified Transit Accounts (QTAs)
Only complete if Employer offers a Qualified Transportation Account administered through EBAM Cloud.
Does client offer QTA?
Yes
No
Type of QTA(s) Offered:
Parking
Mass Transit
Other
Please complete each section for each QTA that will be offered.
Maximum Total Monthly Contribution
Employee Minimum Monthly Contribuion
Monthly Employer Contrivution
Parking
Mass Transit
Other
Do you currently have a QTA?
*
Yes
No
If yes, will rollover dollars be transmitted from your current administrator?
Yes
No
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Section 7: Other Products
Only complete if Employer offers other products through EBA&M
Type of Product(s) Offered:
Dental
Vision
COBRA
Other
Dental Summary
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Vision Summary
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of
COBRA Rates
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of
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Section 8: Eligibility Information
This information is used to establish the PD.
Client Census
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Will you cover part-time employees?
*
Yes
No
Will you cover employees on leave?
*
Yes
No
Spouses Covered
*
Yes
No
Domestic Partners Covered?
*
All
State Mandated
No
Waiting period
*
*EBA&M accepts effective dates indicated on enrollment material. Managing & recording the required waiting periods is the Employer’s responsibility.
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Section 8: Broker Information
Agency Name
*
Agency Tax ID#
*
Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Completed W9
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Broker Name
*
First Name
Last Name
Broker Email
*
example@example.com
Broker Phone Number
-
Area Code
Phone Number
Account Manager Name
First Name
Last Name
Account Manager Email
example@example.com
Verify EBA&M Fee
Verify Broker Fee
Verify Other Fee(s)
Submit
Should be Empty: