Report Information
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First Name |
Last Name |
Relationship To Plan |
| Who is Requesting Report?: |
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| Contact Information |
Email |
Phone Number |
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Information for Reportr |
Plan Name |
Street Address |
City |
State |
Zip Code |
| Plan Data |
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Total Monthly Cost: HealthPlan Premium |
Current Plan Monthly Premium |
New Health Plan/HRA Monthly Premium |
Total Number of Participants |
| Single (EE): |
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| Employee+Spouse: |
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| Employee+Dependent: |
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| Family: |
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Employer Percentage Pay of Health Plan Premium |
Current Plan |
New Health Plan/HRA |
| Single (EE): |
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| Employee+Spouse: |
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| Employee+Dependent: |
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| Family: |
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Total Annual HRA Contributions |
Current Plan |
New Plan
(use only numbers no commas) |
| Single (EE)$: |
N/A
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| Employee + Spouse $: |
N/A
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| Employee + Dependent $: |
N/A
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| Family $: |
N/A
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HRA Transactions Allowed under Plan: (check all that apply) |
Current Plan |
New Plan |
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N/A
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| Over The Counter Section 125 Approved Items (OTC) |
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N/A
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| Major Medical (Hosiptal, Doctor Visits, etc) |
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N/A
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N/A
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Return on unused HRA Funds |
Current Plan |
New Plan |
| Interest Rate % for Unused HRA Funds: |
N/A
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Employer Tax Rates |
Current Plan |
New Plan |
| Federal Tax Rate (%): |
N/A
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| State Tax Rate (%): |
N/A
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HRA Administration and Compliance Fees |
Current Plan |
New Plan |
| One-Time Set-Up Fee ($): |
N/A
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| Participant/Month Fee ($): |
N/A
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| Annual Renewal Fee ($): |
N/A
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