T N E M LL O R N E TI FE N EB A R H

H R A B EN E F IT E N R O L L MEN T
Compa ny Na me:__ _______________ __ _______________ __ _______________ __ ______
Employee:
SS#:
Date of Birth: _______________
Date of Hire: ________________ Effective Date: _______________
Phone: _______________________________________
Address:___________________________________________________________________________________________
Street
City
State
Zip
Email Address: __________________________________________
Do you have an HSA (Health Savings Account) set up:
Medicare Beneficiary
Health Plan:
No  Yes
No Yes, If Yes, Medicare ID:____________________
Company Sponsored Health Plan Spouse/Partner Health Plan Other: _______________________
D e p e n d e n t I n f o – Pl e a s e l i s t a l l e l i g i b l e d e p e n d e nt s & s p o u se .
Name: (Last, First MI)
Date of Birth
Social Security Number
Medicare ID
I hereby elect to participate in my employers HRA plan agreeing to be bound by all terms, condition and
limitations to the Plan. I understand that I must keep copies of all debit card transaction receipts and can be
asked to submit them at anytime throughout the plan year. I also agree that if I cannot produce a copy of the
requested receipt the transaction will be deemed ineligible and I will have to refund the plan for the total
expenses.
Signature of Employee:
Date:
* * Wa i v e r of P a r t i c i p a t i o n * * *
I have been given the opportunity to enroll in the Hea lt h Rei mbu rsement Pla n, but I DO NOT WISH to
participate.
Signature of Employee:
Date:
POBox8592,Essex,VT05451p877.900.MYRX(6979)f877.687.6921
[email protected]