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:
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:
12) Human Resource Contact/Name:
13) Payroll Contact/Name:
14) Telephone #/Ext.:
(Contact Where All Reports Will Be Forwarded)
Section 2. Employee Eligibility Period for Coverage
15) Required Days Worked To Be Eligible:
16) Required Hours Worked to Be Eligible:
17) Employee Entry Period for Cafeteria Plan Will Be:
Please Select One
1st Day of the Month Following The Date of Eligibility
The Date of Hire
1st Day of the Plan Year Following Eligibility
18) Plan Entry Option*:
Employee Entry Option For Plan, *Open
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:
Please Select All That Apply
Weekly Paid(52 Times)
Bi-Weekly Paid(26 Times)
Semi-Monthly Paid (24 Times)
Monthly Paid(12 Times)
20) Is Your Payroll?
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)
Unreimbursed Medical Plan
Limited Purpose Unreimbursed Medical Plan
Limited Purpose HRAs Plan
Section 5. Employee Benefits(Insurance Products Offered)
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
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?
a) Would you like to offer the Carryover/Roll-Over for URM ONLY on your plan?
b) Number of Days following the Close of the Plan or Participant Termination for Claims Submission Run-Out?
Section 7. Flexible Spending Account Bank Set Up (For Office Set Up)
25) Bank Name:
SABC can set up, monitor, and reconcile this clearing account for employer. Do you want this?
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?
Direct Deposit (Required for Reimbursements)
Debit Card* (Debit Card is optional for FSA or HRA Medical)
RX Only 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.
HRA (Integrated with Health Plan Only)
HRA Limited Purpose Dental and/or Vision (Stand Alone)
Option for Employer Name to appear on the Debit Card:
-- 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. Debit Card Plan Co-Pays
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 Fees Paid by: Employer Employee
: Replacement Card Fees Paid by: Employer Employee**
** Replacement Fees paid 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 7% of All Participants aggregate 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.
Select All that Apply
3rd Notice Card Suspended
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.
Subchapter S Corp
Limited Liability Corporation
Limited Liability Partnership
Government Entity or Church
State Agency, School, County, County Hospital, Municipality
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 $175,000 *, 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.
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.
SABC MUST HAVE THE FOLLOWING INFORMATION FOR DOWNLOAD:
GENERAL EMPLOYEE CENSUS OF REQUIRED INFORMATION:
SOCIAL SECURITY NUMBER,
NAME: LAST,FIRST,MIDDLE INITIAL
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)
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.