Employer Certification Form

This form is to be completed by the employer on behalf of the employee being added to the health plan group coverage.

Employer Information

For Medicare reporting, please indicate the number of full-time and part-time employees you currently have on payroll: *
According to the Patient Protection and Affordability Act we are required to know how much the employee is required to pay for their insurance premiums. If the amounts listed below change, you are required to inform Alliance Benefits.

Employer Eligibility Compliance

Please verify that 100% of all Licensed Official Workers on staff are enrolled in The Alliance Health Plan with the exception of being covered under a Spouse’s Employer Plan, Medicare/Medicaid, a Bi-Vocational Employer Plan (this exception does not include a Licensed Official Worker who is enrolled in a ministry cost-sharing program or the government exchange program): *

Employee Reason for Enrolling and Verification

Reason for Enrolling: *

HSA Authorization for Contribution Agreement

Employer Monthly HSA Contribution (Included in monthly premium) *
For 2019, the IRS allows an individual to contribute up to $3,500 and a family may contribute up to $7,000. These limits include the combined total of employer and employee contributions. Employees who are age 55 or older are allowed to contribute an additional $1,000 in catch-up contributions. Any remaining balance in the employee’s HSA will rollover and accumulate year to year.
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