QSEHRA Premium Only (POP) Plan Design

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Purchaser's Name*

First NameLast Name

Purchaser's E-mail*

Administartors Phone*

You or Your Client's Company Name*

Business Address*

Street Address

City State and Zip*

What state is the business incorporated in? If not a corporation, what state is the business domiciled in?*

Company Plan Administrator*

First NameLast Name

Business Federal Tax ID (EIN)*

Plan Year*

Plan will be effective on the first day of:*

...in the year:*

1

Start Date

Waiting Period for New Hires*

DOESDOES NOT

AREARE NOT

Monthly Benefit:

The maximum monthly allowance for 2017 Plans

Employee Only	$412.50
Employee w/ Dependent(s)	$833.33

The maximum monthly allowance for 2018 & 2019 Plans

Employee Only	$420.83
Employee w/ Dependent(s)	$854.17

Monthly Allowance (Employee Only)*

Monthly Allowance (Employee w/ Family) If your plan offers "employee only" coverage or, does not offer a different amount for employees with dependents, restate employee only amount here.*

PYM*

Total Annual Single*

Add comma, do not add dollar sign.

Total Annual Family*

Add comma, do not add dollar sign.

YesNo

Annual Deductible (Employee Only) If no deductible input "0"*

Annual Deductible (Employee w/ dependent(s)) if no deductible input "0"*

YesNo

Minimum Hours per Week Part Time Employees must work to be eligible:

Monthly Allowance for Part Time (Employee Only)

Monthly Allowance for Part Time (Employee w/ Family)

What is your total QSEHRA annual benefit amount for Part Time "Employee Only"

What is your total QSEHRA annual benefit amount for Part Time "Employee w/ Family"

Annual Deductible (Part Time Employee Only) If no deductible input "0"

Annual Deductible (Part Time Employee w/ dependent(s)) if no deductible input "0"

Plan Number - If this is your first plan (new plan), choose 501. Second plan, 502...etc.*

How many days do participants have to submit reimbursement requests from date of expense? (Back dated plans allow longer)*

How many participants will you start with?*

Calculation

Secure Checkout with Stripe*

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QSEHRA Plan Design