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WRAP Document Application
EMPLOYER CONTACT INFORMATION
Legal Name of Organization: ___________________________________________________________________________
Federal Employer Tax ID #: _______________________ Date Incorporated/Organized: ___________________________
Mailing Address: ____________________________________________________________________________________
City: _________________________________________ State:____________________ Zip:_______________________
EMPLOYER CONTACT INFORMATION
Contact Name: _________________________________ Contact Email:________________________________________
Phone (w/Ext.):________________________________ Fax #:_______________________________________________
BROKER CONTACT INFORMATION
By checking this box, you authorize to disclose the information provided in this application to the Broker
identified below. You understand that O.C.A. is authorized to share this information with the named broker
until you have provided written notice to OCA of any changes.
Broker Name: ________________________________ General Agency Name: _______________________________
Phone (w/Ext.):_______________________________ Broker Email:________________________________________
INVOICE REMITTANCE INFORMATION (Complete if Someone other than Employer is Responsible for Invoicing)
Invoice Contact: ____________________________________________________________________________________
Complete Mailing Address: ____________________________________________________________________________
Phone: _______________________________________Email:________________________________________________
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Group Comprehensive Medical (i.e. Horizon HSAc EPO) (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ________________
This benefit is offered through the employer’s cafeteria plan.
Group Comprehensive Medical (i.e. Horizon HSAc EPO)
(Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ________________
This benefit is offered through the employer’s cafeteria plan.
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Dental (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ________________
This benefit is offered through the employer’s cafeteria plan.
Dental (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ________________
This benefit is offered through the employer’s cafeteria plan.
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Vision (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
Vision (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Group Term Life Insurance for employees (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
Group Term Life Insurance for employees (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Identify the insurance carrier that issues the policy: ____________________
What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Group Supplemental Life Insurance for employees (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
Group Supplemental Life Insurance for employees (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Group Dependent Life Insurance for Spouse and/or Dependent Child (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Identify the insurance carrier that issues the policy:____________________
What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Short Term Disability Benefits (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Employees are required to contribute towards the cost of the coverage.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________
What are the eligibility requirements for this benefit option?_________________________________________
This benefit is offered through the employer’s cafeteria plan.
.
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Short Term Disability Benefits (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Employees are required to contribute towards the cost of the coverage.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________
What are the eligibility requirements for this benefit option?_________________________________________
This benefit is offered through the employer’s cafeteria plan.
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Long Term Disability (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________
What are the eligibility requirements for this benefit option?__________________________________________
When does coverage begin if elected?____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Long Term Disability (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________
What are the eligibility requirements for this benefit option?__________________________________________
When does coverage begin if elected?____________________________________________________________
This benefit is offered through the employer’s cafeteria plan.
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Health Reimbursement Arrangement (Please provide summary of benefits and plan document if available)
Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________
What are the eligibility requirements for this benefit option?__________________________________________
When does coverage begin if elected? ____________________________________________________________
If there are more than two options, please provide the relevant information with respect to each option on an
attachment to this application.
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Health FSA (General Purpose) (Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Identify the claims administrator:_________________________________________________________
This benefit is funded through a trust.
What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected?____________________________________________________________
Limited Purpose Health FSA
(Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Identify the claims administrator:_________________________________________________________
This benefit is funded through a trust.
What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________
Dependent Care FSA
(Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Identify the claims administrator:_________________________________________________________
This benefit is funded through a trust.
What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________
Benefits to wrap…
Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option
identified below that you desire to aggregate into a single plan under the wrap document.
Other ________________________________________________ (Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________
What are the eligibility requirements for this benefit option?__________________________________________
When does coverage begin if elected? ____________________________________________________________
Other _______________________________________________ (Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________
Self-funded. If self-funded, identify the claims administrator:_______________________________
This benefit is funded through a trust.
Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________
What are the eligibility requirements for this benefit option?__________________________________________
When does coverage begin if elected? ____________________________________________________________
Participating Employers: Please Identify all of the employers whose employees participate in one or more of the benefits identified above, the specific benefits in which their employees participate, and whether they are a member of the same “controlled group” or not.
Employer name
Identity of benefits in which the
employer’s employees participate
Whether or not the employer is in the same
controlled group as the plan sponsor
The employer’s employees
participate in all of the benefits
identified above.
The employer’s employees only
participate in the following
benefits:
The employer is a member of the same
controlled group as the plan sponsor.
The employer’s employees
participate in all of the benefits
identified above.
The employer’s employees only
participate in the following
benefits:
The employer is a member of the same
controlled group as the plan sponsor.
The employer’s employees
participate in all of the benefits
identified above.
The employer’s employees only
participate in the following
benefits:
The employer is a member of the same
controlled group as the plan sponsor.
The employer’s employees
participate in all of the benefits
identified above.
The employer’s employees only
participate in the following
benefits:
The employer is a member of the same
controlled group as the plan sponsor.
This page should be completed for “Controlled groups” only. To view the definition of a controlled
group, please go to http://www.irs.gov/pub/irs-tege/epchd704.pdf
Important Information
You should keep in mind. What are the pros and con’s of an “Umbrella Wrap”? Few would dispute that ERISA-covered plans are subject to a certain amount of required compliance baggage. Among other things, each ERISA plan is required to: be maintained pursuant to a formal plan document; be described to participants through a summary plan description; have assets maintained in an ERISA-compliant trust, and file an annual Form 5500 (when applicable) each year. The theory behind an Umbrella Wrap is that the cost of the ERISA infrastructure can be spread across many benefits resulting in less costly administration for each benefit that is provided. Since ERISA does not prescribe a specific plan design for welfare benefits, the plan sponsor is free to wrap together one or more other wise unrelated welfare benefits into an Umbrella Wrap document. That said, plan sponsors may unwittingly increase their Form 5500 obligations when adopting an Umbrella Wrap. For example, an employer that offers dental coverage with 70 participants and vision coverage with 40 participants (only 10 of whom also have dental coverage) may subject itself to Form 5500 requirements for the first time when the benefits are wrapped (i.e., because there are now 100 participants in a single plan). Likewise, an employer that offers unfunded benefits (such as a health FSA or HRA) that may otherwise be exempt from ERISA’s audit requirements may subject the unfunded benefits to the audit requirement when the benefit is “wrapped” with a funded benefit (e.g., primary health coverage).
Fee Information
By signing this document you are stating that you have had an opportunity to review this document in its entirety.
Additionally that you agree to the terms and conditions set forth by O.C.A. Benefit Services.
______________________________________________________________________________________________
Employer Signature Date
$650 Annual Fee (The renewal fee will be reduced to $300 for preparation of Summary of Material Modification
(SMM). If new Plan Document and SPD is required, O.C.A. will revert back to the annual fee of $650.)
o Includes Wrap Document and Summary Plan Description
o Any mid-year changes are included at no additional cost. (Client must notify O.C.A of any changes)
o Service automatically renews each year and is subject to the annual fee
o Client may cancel services 30 days prior to the renewal. A written notice to O.C.A. is required.