ICHRA Set-Up Form
Completing and submitting the ICHRA Employer Group Form
Thank you for choosing HSA Insurance for your ICHRA business. To get started, please follow the instructions below.
Step 1: Complete the Employer Group Set-up Form
Fill in the required details on the following page to initiate the employer group account setup.
Step 2: Confirmation and Account Creation
After submitting this form, a member of our team will reach out to confirm receipt. We will also begin the process of creating a parent company account for the employer group in our database.
Step 3: Equip Your Clients with the Power to Choose Coverage
Once the parent account is created, you will receive a unique shopping link for employees. You can retrieve the unique shopping link in your broker portal under Easy Enroll for ICHRA. This link will have your broker information and employer group details embedded, simplifying the enrollment process for employees. If enrolling outside of the annual individual open enrollment period, we also require a copy of the ICHRA employer notice to be uploaded. A copy of the notice should be sent to ichra@hsainsurance.com upon submission of this form. This way, our ICHRA support team can quickly assist employees enrolling in an individual plan under ICHRA.
Step 4: Manage with Ease
The individual enrollments will be tied to the parent company account to help you effortlessly track, administer, and manage your ICHRA enrollments. Stay organized and focused on growing your ICHRA business, while we handle the administrative complexities.
Should you require any support or have questions at any point in the process, don’t hesitate to contact our dedicated ICHRA team. You can reach our team by phone at 781-228-2222, select option 4 for ICHRA. Or email us at ichra@hsainsurance.com.
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Broker Information
Broker Name
*
First Name
Last Name
Agency Name
*
Broker Email
*
example@example.com
If the HRA administrator is listed as the broker, list an additional broker here:
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Employer Group Information
Employer Group Name
*
Employer Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
Plan Start Date
*
/
Month
/
Day
Year
Date
Number of Full Time Employees
*
Expected MA Enrollments
Expected RI Enrollments
Primary Contact
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Employer Tax ID
*
SIC Code (Industry Classification)
*
SIC Code List: https://www.sec.gov/corpfin/division-of-corporation-finance-standard-industrial-classification-sic-code-list
Party Responsible for Payment of Premium
*
Please Select
Employee Pay Model
TPA/Employer Pay Model
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HRA Administrator
TPA HRA Administrator Information
HRA Administrator Name
*
Primary Contact
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Primary Contact Phone Number
Please enter a valid phone number.
Submit
Should be Empty: