employer_sub_agreement

UNITARIAN UNIVERSALIST ORGANIZATIONS

Subscription Agreement for Employers
Name of the Congregation*
Tax ID*
EIN
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
THE EMPLOYER ELECTS TO OFFER (check all that apply):*

Standard PPO benefits - GoldHigh deductible PPO benefits with and without HSA- SilverHigh deductible PPO benefits with and without HSA - BronzeMedicare Supplement benefitsDental/VisionLife InsuranceLong Term DisabilityHospital IndemnityAccident Indemnity
For Congregations Offering Any Level of the UUA Health Plan:

The Unitarian Universalist Association has established and maintains the Unitarian Universalist Association Employee Benefits Trust (the “Trust”), which provides benefits under the Unitarian Universalist Organizations Health Plan (the “Plan”). By signing this agreement, you are subscribing to and agreeing to the terms of the Plan and the Trust and you become a “Subscribing Employer.” As a Subscribing Employer you may enroll Eligible Employees, Eligible Retirees and their Dependents (as those terms are defined in the Plan and the Trust), subject to the specific elections below.
HEALTH INSURANCE COVERAGE EFFECTIVE DATE: The Subscribing Employer elects to make coverage effective on (check one):*

Date of hireFirst day of the month following date of hireFirst day of the month following a 30-day waiting period (enroll within 30 days of hire)First day of the month following a 60-day waiting period (enroll within 30 days of hire)90-day waiting period (enroll within 30 days of hire)
HEALTH PLAN EMPLOYEE ELIGIBILITY: Our congregation understands that all eligible employees must be offered coverage, though we may contribute different amounts for different employee premiums. We agree to keep records of employee elections and have them available for audit.*

Agree
HEALTH PLAN AUDIT INFORMATION: We agree to keep records of employee elections and have them available for audit.*

Agree
HEALTH PLAN EMPLOYER CONTRIBUTIONS

The Subscribing Employer agrees to contribute the following amounts toward the monthly cost of health insurance coverage:

Employees scheduled to work at least (choose one) hours per week or hours per year:
- Self-Only Coverage:(% or $ )
- Dependents:(% or $ )
Employees scheduled to work fewer than (choose one) hours per week or hours per year:
- Self-Only Coverage:(% or $ )
- Dependents:(% or $ )
If additional details about your contribution policy are necessary, please provide additional details here – For example, specify if your contribution is based on the cost of a particular plan level, capped at a specific dollar amount, or follows any other defined criteria: Type a label

PAYMENT TERMS:
All payments must be submitted by the 15th of each month and are payable to UUA Insurance Plans.

Our congregation understands that we must keep accurate records of employee contributions, report those contributions annually to the
UUA, and have the records available for audit.
You can receive a copy of the Plan and the Trust. Please direct questions to the UUA Health Plan (888) 792-7496, or to insuranceplans@uua.org. Visit us on the web at www.uua.org/insuranceplans.
Treasurer's Name*

First NameLast Name
Congregation ID*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

UNITARIAN UNIVERSALIST ORGANIZATIONS

You can receive a copy of the Plan and the Trust. Please direct questions to the UUA Health Plan (888) 792-7496, or to insuranceplans@uua.org. Visit us on the web at www.uua.org/insuranceplans.