Roger Jorgensen, RHU, REBC Health and Wellness Sales Consultant – HRA/FSA/HSA/COBRA/VEBA 8200 Commonwealth Suite 200 Eden Prairie, MN 55344 952.253.1259 Rita Cooper Health and Wellness Account Executive - FSA/HRA/HSA/COBRA/VEBA 8200 Commonwealth Drive, Suite 200 Eden Prairie, MN 55344 952.253.1259 IMPLEMENTATION SERVICES Stacie Ravenhorst, CFC FSA/HRA/HSA/VEBA Implementation Specialist 201 East Clark Street Albert Lea, MN 800.898.9344 ext. 1189 PLAN ADMINISTRATION SERVICES Michelle Hintz, CFC Anne McGinnis Health and Welfare Services Manager HSA Supervisor 201 East Clark Street 201 East Clark Street Albert Lea, MN 56007 Albert Lea, MN 56007 800.898.9344 ext. 1177 800.898.9344 ext. 1176 April Van Hove 201 East Clark Street Albert Lea, MN 56007 800.898.9344 ext. 1200 PARTICIPANT CUSTOMER SERVICE Alerus Customer Service Toll Free Phone: 877.661.4727 (Live operators Mon-Fri 7 a.m. – 6 p.m. Central Time) Toll Free Fax: 866.808.7823 Participant Website: . Your plan will be assigned an administrator by the implementation specialist – you will receive this administrator’s contact information once setup is complete. Additional administrative contact information will be provided by implementation specialist prior to Implementation effective date. Please see last page of this communication for important disclosure information. II. EMPLOYER INFORMATION
Employer Name: Date: Effective Date: Street Address: City: State: Zip: Federal Tax ID: State of Incorporation: Type of Employer Entity (please check one): C Corporation S Corporation Partnership Sole Proprietorship Limited Liability Company Non-Profit Organization Government Church Primary Contact: Phone: Title: Fax: Billing Contact: Phone: Title: Fax: Payroll Contact: Email: Phone: Payroll Frequency: Date of 1st payroll deductions: If Bi-Weekly: 24 or 26 Is Payroll Outsourced? Yes No If yes, please identify vendor: Is COBRA Outsourced? Yes No If yes, please identify vendor: Broker’s Phone: Broker’s Email: Broker (Agent) Name: Broker’s Company Name: Additional Contact(s) for Broker: Name: Phone: Email: III. PLAN INFORMATION HSA INFORMATION HSA monthly admin fee paid by: Employer Employee # of eligible employees: # of HSA participants: Transfer from other vendor: Yes No Is the employer contributing to employees’ HSAs? Yes No If yes, are the contributions: Flat Dollar Matching Other ER contribution applied: Annually Quarterly Monthly With each payroll Other Is there a Sect. 125 Cafeteria plan document in place? Yes No Is a new Sect. 125 Cafeteria plan document required? Yes No Is there a limited FSA in place? Yes No Additional Comments: FSA INFORMATION Plan Year Begin: End: Mid-year Takeover Yes No Benefits offered: Health FSA Limited Purpose FSA Limited Purpose FSA with Post Deductible expense Dependent Care FSA Parking/Transit Approx. number of eligible employees: Approx. number of participants: FSA Contribution Annual Maximum: IRS Max Other $
HSA card provided for FSA Plan: Yes No Debit card provided for: Health FSA Dependent Care FSA Claims processing weekly on: Monday Tuesday Wednesday Thursday Friday Claims Funding Options: (pg. 6) Option 1: Run on Alerus acct and ACH pull total back from employer Option 2: Run on employer’s acct $500 Carryover Feature: (Medical and Limited FSA Only) Yes No Did Carryover to previous FSA plan year: Yes No 2 ½ Month Grace Period: Yes No If yes: 2 ½ months Other For: Medical Dependent Care Claims run out period: plan year end or grace period end) 30 days 60 days 90 days Other Additional Comments: IV. PARTICIPANT CENSUS DATA The following census data is required for the setup of your participants. This data should be submitted to Alerus in an Excel spreadsheet. Each bulleted item represents a separate column required in the spreadsheet. If a specific column does not apply, (i.e. division) simply leave that column blank. HSA/FSA SPREADSHEET COLUMNS REQUIRED Employee ID # (no dashes or spaces)