Section 1. Employer Information

New Group Form


1) Employer (Legal) Name:   (List If A D.B.A. or Any Subsidiaries)

2) Current Plan Year: Begin Date: End Date:

Change/Short Plan Year Date(If Applicable): Begin Date: End Date:

  • Address Line 1:
  • Address Line 2:
  • City State: Zip:

4) Federal Tax Identification Number:

5) Fiscal Year:

6) Number of Locations:

6b) Employer Web Address:

7) Total Number of Eligible Employees?

8) Has Your Company Ever Had A Cafeteria Plan? Yes No

9) Initial Effective Date of Plan?

10) Form 5500 Filing Number: #

11) Appointed Plan Administrator Name:
Title:
Email Address: Telephone #/Ext.:

12) Human Resource Contact/Name:
Title:
Email Address: Telephone #/Ext.:

13) Payroll Contact/Name:
Title:
Email Address: 14) Telephone #/Ext.:
(Contact Where All Reports Will Be Forwarded)

Section 2. Employee Eligibility Period for Coverage

15) Required Days Worked To Be Eligible: Days
16) Required Hours Worked to Be Eligible: Hours
17) Employee Entry Period for Cafeteria Plan Will Be:
If Other:
18) Plan Entry Option*: Employee Entry Option For Plan, *Open   **Closed
*Open Means Employees May Enter Plan Upon Meeting Eligibilty, Closed Means Entry Is Only At Plan Renewal.

Section 3. Employee Payroll Data

19) Pay Modes:
For Each Mode of Pay Marked, Indicate the First Pay Date for the Plan Year. WEEKLY) First Pay Date: By Pay Mode Date:
BI-WEEKLY) First Pay Date: By Pay Mode Date:
SEMI-MONTHLY) First Pay Date: By Pay Mode Date:
MONTHLY) First Pay Date: By Pay Mode Date:
20) Is Your Payroll?   In House   No
If Out Sourced, List Payroll Company Name, Address, Telephone and Contact Name in the space provided:


Section 4. Employee Benefits Offered:

Premium Only Plan
Plan Sale Only(with non-discrimination testing)
Plan Sale Only(without non-discrimination testing)

Flexible Spending:
      Dependent Care
      Unreimbursed Medical Plan
      Limited Purpose Unreimbursed Medical Plan

Additional Services:
      HRAs Plan
      Limited Purpose HRAs Plan
      HSAs Plan
      Insurance Sales

Section 5. Employee Benefits(Insurance Products Offered)

Insurance Benefit TypeInsurance Carrier/ProviderMark X ONLY If You Want This A Mandated BenefitDeduction Mode of Benefit(s)

Section 6. Flexible Spending Accounts (Complete Only If Offering This Benefit)

For Unreimbursed Medical (URM)
22) Unreimbursed Medical Expenses Plan Year Maximum is: $
(Cannot exceed $10,000 for State of Mississippi Agencies/Schools Only)
23) In the event a participant, who participates in an unreimbursed medical spending account, terminates during the plan year, there are two options in which to choose for your plan. (Please select A or B)
Type A: Cobra Term Style

The Participant’s Salary Reductions will terminate, as will the participant’s election to receive reimbursements. The Participant will not be able to receive reimbursements for Unreimbursed Medical Spending Expenses incurred after his or her participation terminates. However, such Participant (or the Participant’s estate) may claim reimbursements for any Unreimbursed Medical Spending Expense incurred during the Period of Coverage prior to termination, provided that the Participant (or the Participant’s estate) claim is filed with in the (60) day grace period, following the end of the plan year.

Type B: Final Pay Style

Employees participating in Unreimbursed Medical Spending Accounts participate for the full Plan Year, the Plan does not terminate when the employee terminates. Final reduction of the Participants Plan Year Annual election will be deducted from the Participant’s final paycheck. The Participant ceases to be a Participant at the close of the Plan Year and is allowed the same grace period as a current employee.


24) Would you like to offer the Grace Period -- 2 1⁄2 month extension for URM ONLY on your plan?
Yes No
a) Would you like to offer the Carryover/Roll-Over for URM ONLY on your plan?
Yes No
b) Number of Days following the Close of the Plan or Participant Termination for Claims Submission Run-Out?
Yes

Section 7. Flexible Spending Account Bank Set Up (For Office Set Up)

25) Bank Name:
Location:
SABC can set up, monitor, and reconcile this clearing account for employer. Do you want this? Yes No
26) BANK ROUTING TRANSIT NUMBER:
27) BANK ACCOUNT NUMBER:
28) AUTHORIZED SIGNER FOR FLEXIBLE SPENDING ACCOUNT REIMBURSEMENTS:
SABC Offers to sign for Company, This will allow us to mail checks directly to Individual. Do you want this? Yes No
29) Reimbursements: Direct Deposit (Required for Reimbursements)
Debit Card* (Debit Card is optional for FSA or HRA Medical)
RX Only Card
Open Card

Section for Debit Cards with Flexible Spending (for office set-up)

Debit Card Set-up: Timeline for Card delivery - 30 day Lead-Time for Client Set Up and for Cards to be issued after 6% Pre-funding is received.
Cards Auto Substantiate, for RX Drugs at most major chain pharmacy’s with an IIAS program.
Options:
Health FSA
HRA (Integrated with Health Plan Only)
HRA Limited Purpose Dental and/or Vision (Stand Alone)

Expenses:
MEDICAL
DENTAL
VISION
RX/PHARMACY
OTHER
Option for Employer Name to appear on the Debit Card:

Debit Card Plan Co-Pays -- In order for the SABCFlex Card to Auto Substantiate, co-pays MUST be listed and must be whole dollar amount - No Percentages! If plan has no co-pays, skip this part.

Please identify Co-payments on the items below:
Emergency Room $ Office Visit $ Ambulance Other $
Pharmacy: Generic $ Preferred $ Non-preferred
Pharmacy Mail Order: Generic $ Preferred $ Non-preferred
HRA Limited Purpose Plan: Dental $ Vision $

Card Fees: (Per Card) $ Minimum Card Billing per month $
Card Feeds Paid by: : Employer Employee
Replacement Card Feeds Paid by: : Employer Employee**
** Replacement Fees paud by the Employee will be deducted from account balances.


Debit Card Funding:
SABC will request Debit Card funding based on the Card Company’s requirements of having 6% of All Participants total annual amounts received, before the Company Card Account is opened and before Cards for Participants may be ordered.

Employer will additionally be required to fund the Card based on replenishing records received each Monday from the Card company “Benny.” This is based on participant card utilization from the week before. Swiped amounts sync up with our SABC system daily. Should additional funding be required by the Card Company, SABC will notify you of balance amounts to supplement.

This is not a Paper Free process, Card Participants will be required to substantiate expenses swiped on all expenses except RX received at a Pharmacy with an IIAS approved program. (Standard is every 20 days, and will default if not changed)

Emailed Notices for Validation
Participants are required to Validate expenses. Notices are sent every 20 days. By the 3rd Notice, the card is suspended until Card Participant validates or repays the expense. Upon receipt of validation or repayment, the card will unsuspended.

Section 8. HIPAA Privacy Rule Requirements

With respect to disclosures of Protected Health Information (PHI) under the HIPAA PRIVACY RULE. the Employer acknowledges and agrees that the Service Provider (SABC) shall only disclose PHI in its possession to the following employees who are identified by the Employer as (Designated Persons) in accordance with 45 C.F.R. § 164.504(f), and that such disclosures are solely for purposes of carrying out plan administration functions that the Employer performs for its Group Health Plan and/or Health FSA Plan such as (1) Who is the appointed privacy officer?; (2) Who should employees contact to request a list of accounting of PHI disclosures?; (3) Who should employees contact to obtain a paper copy of their Summary Plan Description, or Privacy Notice; (4) Who should employees contact to file a complaint with the Plan over PHI violations; (5) Who should employees contact to request an amendment to PHI?; and (6) List personnel who will have PHI access for benefits administrations purposes only. Plan Administrator will be included in this list.

30) PLEASE COMPLETE PHI ELIGIBLE: [LIST OF DESIGNATED PERSONS BY NAME OR POSITION

NAME/OR POSITION/OR CLASS OF EMPLOYEE:


  • Privacy Officer     TITLE:
    SABC will only disclose information on PHI to this list of personnel provided for benefits adminstration purposes only.

    Section 9. NON-DISCRIMINATION TESTING

    BUSINESS ENTITY TYPE: Required Information (Employers Must Complete All Portions) 31)Please mark the box for the type of business that applies. If you are unsure, please speak to your corporate secretary, as this information must be accurate.

    ALL Participants in a Section 125 plan must be “employees.” “Employees” are defined by the regulations as to exclude self-employed Individuals. Partners, owners of a Sole proprietorship and shareholders in a Subchapter S Corporation who owns more than2% of the stock of the corporation. However, partnerships, sole proprietorships And Subchapter S Corporations are not prevented from sponsoring a Cafeteria Plan for the benefit of their common-law employees. (Example: If you are a 2% owner of a Subchapter S Corporation, cannot Participate). Based on the above, please list owners that would not be eligible:

    32) LIST OWNER(S) NAME:       SOCIAL SECURITY NO:
         
         
         

    Section 9. CONT. NON-DISCRIMINATION TESTING (Key, Top Paid Group and Highly Compensated Employees)

    Directions: Please list employees that apply, give name, social security number and indicate the number(s) of the category items below that apply. List employees, shareholders and owners, as well as owner relatives that work for the company.
    Please base your answers on the preceding calendar year (prior year) income.

    • 1 - Officer(s) of the Company with greater than $170,000 *, as indexed, "Key Employees"
    • 2 - Employees with 5% Ownership of the Employer -* "Key Employees"
    • 3 - Employees with 1% Ownership of the Employer with income greater than $150,000 (not indexed) "Key Employees"
    • 4 - Employees who are a spouse or dependent (and relationship) of any individual falling into the above categories, "Key Employees"
    • 5 - Employee with 5% Shareholder stock or voting power (one any day of the year or the preceding year) * "Highly Compensated Employees and Key Employees"
    • 6 - An Officer of the Company "Highly Compensated Employee"
    • 7 - Employees with compensation of $120,000 or greater*, as indexed, "Highly Compensated Employees"
    *Limits above are based on the IRS Indexed Contribution and Benefits Limits for qualified plans (IR 2004-122), as indexed.
    LIST EMPLOYEE NAME:SOCIAL SECURITY NO.:CATEGORY NUMBER

    Employees properly excluded under a plan’s eligibility may nevertheless have to be counted for purposes of the Code’s nondiscrimination tests. Excluding too many employees could cause the plan to fail one or more of these tests. Many nondiscrimination issues can be avoided through plan design. SABC performs Eligibility Test, in which IRS requires the plans eligibility be fair, consistent, and reasonable. Some employees may be excluded (on a uniform basis) because of their age, limited services, etc. SABC performs the Utilization test, (sometimes called the concentration or contributions and benefits tests) where comparable benefits are utilized by a fair number of employees at all compensation levels and in all positions. This test includes the Key Employee Concentration Test and the Owner’s Test (To insure that Keys do not receive more than 25% of the total benefits under Code 125 plan) The Ownership and Key Test does not apply to collectively bargained plans, or officers or employees of governmental entities, but the highly compensated test does.


    Authorized By    



    CENSUS INSTRUCTIONS

    SABC MUST HAVE THE FOLLOWING INFORMATION FOR DOWNLOAD:
    GENERAL EMPLOYEE CENSUS OF REQUIRED INFORMATION:
    SOCIAL SECURITY NUMBER,
    NAME: LAST,FIRST,MIDDLE INITIAL
    ADDRESS 1:
    ADDRESS 2:
    CITY:
    STATE:
    ZIP:
    DATE OF BIRTH:
    DATE OF HIRE:
    PAY FREQUENCY: (example Monthly)
    (BY HOW EMPLOYEE IS PAID, MONTHLY, SEMI-MONTHLY, WEEKLY, BI-WEEKLY)
    NUMBER OF DEUCTIONS: (12 ETC.)
    GROSS PAY: (LIST AMOUNT BY HOW PAID, EXAMPLE MONTHLY, SEMI-MONTHLY, WEEKLY, BI-WEEKLY)
    LOCATION NUMBER: IF YOU HAVE SEVERAL LOCATIONS, OR AS AN IDENTIFIER FOR A DIFFERENT DEPARTMENT OR CLASS. (PLEASE PROVIDE LIST OF LOCATIONS AND MATCHING ID NUMBER)
    LIST INSURANCE PRODUCTS BY TYPE: Health, Dental, Vision, etc.
    (List Amounts by how they are deducted.)
    EXAMPLE: MONTHLY, SEMI-MONTHLY WEEKLY, BI-WEEKLY
    (EXAMPLE) (Be sure to include amount of product, by how deducted)
    HEALTH- $40.00 Bi Weekly (Only list portion paid by Employee)
    DENTAL
    VISION
    CANCER
    INTENSIVE CARE
    HOSPITAL INDEMNITY
    MEDICAL SUPPLEMENT
    Please provide name of the product carrier, i.e., Example STATE Health = Blue Cross/Blue Shield, and please indicate if products are not deducted the same way the employees are paid. (Example: Employee paid 26 times a year, deductions are 24 times a year.)
    Please send a copy of each insurance billing listed as a deduction, so SABC may determine cafeteria plan eligibility of the product.
    When completing this form.
    Please contact Valerie Givens, with SABC @ 601-856-9933,
    She will help you go thru the form faster.