CarStar Jerry Rhynes Collision
Individual Coverage HRA Enrollment/Change/Termination
Full Name
*
Hire Date
*
Date of birth
*
Phone
*
Email
*
Address
City
State
Zip code
*
Spouse Name
spouse soc sec
spouse_dob
Spouse's Phone
UpLevel
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Organization
Children's names, Soc Sec, DOB, Gender
ICHRA agreement
*
By checking this box I acknowledge I understand that I am eligible to receive reimbursement of all Individual premiums being offered by this HRA plan.
I agree that if I am enrolling in the company ICHRA plan, I attest that I and all my family members listed above are covered (or will be covered) by ACA qualified individual health coverage (or Medicare). This coverage is (or will be) effective on or before your company ICHRA plan effective date.
I recognize I must submit third party substantiation/EOB and a Reimbursement Request Form to the Plan Administrator.
I recognize that any expenses I submit for reimbursement must not be reimbursed by any other source. Tax-free or otherwise.
I have read the Individual Coverage Health Reimbursement Arrangement Summary Plan Description and agree to abide by the terms of the Plan Document.
I will not make a contribution to an HSA for this calendar year.
Opt-In or Opt-Out
*
Yes, Enroll Me in the ICHRA Plan
No, I Opt-Out of the ICHRA Plan
Signature
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Insurance Plans