HEALTH REIMBURSEMENT ARRANGEMENT - ENROLLMENT FORM
[Pages:1]HEALTH REIMBURSEMENT ARRANGEMENT - ENROLLMENT FORM
You must complete and return this form. Please print.
Name: ____________________________________________________________ Social Security #: ____________________ Home Address: _____________________________________________________ Email: _____________________________ City, State, Zip: _____________________________________________________ Phone: ____________________________ Date of Birth: ________________________ Gender _____________ Employer/Division: ____________________________
As a Participant in my Employer's Health Plan I understand that I am eligible to receive certain reimbursements through the Company's Health Reimbursement Arrangement (HRA); I have elected the following coverage under my Employer's Health Plan:
HEALTH INSURANCE ELECTION: SINGLE
DOUBLE
FAMILY
Insurance Plan: __________________________________ HRA Amount: _________________________
Effective Date of Coverage: _____________________________________________________________
I understand that the employer funded HRA account is provided to reimburse eligible deductible expenses under my High Deductible Health Insurance Plan and other qualified medical expenses as allowed by my employer per the HRA plan document. All other expenses are my responsibility and will not be reimbursable to me through my HRA account.
Please Complete the Following Dependent Information
Last Name_______________________ First Name ______________________ Date of Birth ____/____/____
Dependent's SS#: _________________ Relationship: Spouse Domestic Partner
Gender: M F
Last Name_______________________ First Name ______________________ Date of Birth ____/____/____
Dependent's SS#: _________________ Relationship: Child
Gender: M F
Last Name_______________________ First Name ______________________ Date of Birth ____/____/____
Dependent's SS#: ________________ Relationship: Child
Gender: M F
Last Name_______________________ First Name ______________________ Date of Birth ____/____/____
Dependent's SS#: ________________ Relationship: Child
Gender: M F
___________________________________________ _____________________
Employer Signature
Date
Fax Toll Free: 877-723-0147 or email to processing@
No Fax Machine? Mail to: American Benefits Group P.O. Box 1209, Northampton, MA 01061-1209 ? 800-499-3539
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