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Health Reimbursement Arrangement

Also called fixed contribution plans, personal care accounts, or health care account plans.

These are actually accounts set up by you in your employee's name. Typically, you provide a high-deductible medical plan and establishes an HRA that pays for your employee's eligible out-of-pocket medical expenses using employer funds. These plans provide your employee with an incentive to be conservative in health care spending because funds left at the end of the year can be rolled over from year to year and saved for future medical expenses.

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General Information

This section only needs to be completed once for multiple lines of coverage

Name of Business:

Name of Owners/Officers:

Contact Name:

Contact Phone & Fax:

Phone: Fax:

Contact E-mail Address:

Address:

City:

State: Zip:

Business Info:

C-Corporation
S-Corporation
LLC

Sole-Proprietor

Partnership

LLP/Other

Years in Business:

Fed. Tax ID or Social Security Number:

Business Description:

Current/Previous Insurance Information

Current insurance company:

Describe Your Current Health Plan:

Policy Period:

Effective Date: Expiration Date:

Benefits Information

Deductible:

Quote PPO:

No Yes

Doctor's Copay:

Quote HMO:

No Yes

Drug Copay:

Quote POS

No Yes

Quote Group Life Coverage

No Yes

Quote Dental Coverage:

No Yes

Life Amount:

Quote Disability Coverage:

No Yes

Census Data Information

*Important Note*

If you have more than 10 employees, please open this Health Census Form (Adobe pdf) and

save it to your computer to type directly on it, or print it out to complete it by hand.

If you have 10 or less, complete your information below:

Employee Name	Sex	Dependent Status	DOB/AGE	Spouse DOB/Age	#of Children	Employee's
Employee Name	Sex	Dependent Status	DOB/AGE	Spouse DOB/Age	#of Children	State	Zipcode
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F

Additional Comments & Information

Please tell us anything else you think might be helpful to know in order to provide accurate insurance quotes:

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