Employer Certification Form

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

Employer Information

Employer Name *

Employer Locale/Church Code

Employer Tax ID # (EIN) * 🛈

Employer Phone

Employer Fax

Employer's Physical Address (Street, City, State, Zip) *

Employer's Billing Address (if different)

For Medicare reporting, please indicate the number of full-time and part-time employees you currently have on payroll: *

1-19 Employees

20-99 Employees

100 + Employees

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.

Percentage of health plan premiums paid by the employer: *

Percentage of health plan premiums paid by the employee: *

Employer Eligibility Compliance

Please verify that 100% of all Licensed Official Workers on staff who work 30 or more hours per week are enrolled in The Alliance Health Plan with the exception of being covered under a Spouse’s Employer Plan, Medicare/Medicaid/Tricare/VA, 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), or the worker is age 65 or older and has other health plan coverage: *

Yes

No

Employee Reason for Enrolling and Verification

Employee Last Name *

Employee First Name *

MI

Employee's Job Title: *

Employee's Total Annual Salary (needed for life and disability insurance)

Qualifying Effective Date * +

Reason for Enrolling: *

HSA Authorization for Contribution Agreement

Employer Monthly HSA Contribution ("Silver Plan only" Included in monthly premium) *

HSA Authorization for Contribution Agreement (continued)

I understand that employees are not eligible to participate in an HSA if:
• They are enrolled in Medicare, Tricare, or a Veteran’s plan
• They are enrolled in additional coverage that is not a High Deductible Health Plan (HDHP)
• They are claimed as a dependent on another person’s taxes

I hereby authorize ALLIANCE BENEFITS to withdraw funds for the above HSA employee contribution listed.

I understand HSA employee contributions are included in the health plan insurance premium and will be billed at the same time. After the billing is collected, HSA funds will be deposited into the employee’s account by the 10th of every month. Changes (including termination of employment) to contributions must be submitted to Alliance Benefits by the 25th of the month to be included in the following month’s billing. HSA contributions cannot be refunded once collected.

All HSA employer and employee contributions must be reported on employee’s W-2, Box 12, Code W.

I have read the above HSA Authorization for Contribution section of this form and agree that it is the participant’s responsibilityto be in compliance with IRS rules regarding their HSA. Alliance Benefits is not responsible for an ineligible employeeparticipating in an HSA. Alliance Benefits must be notified if an employee is ineligible. Tax penalties may be incurred by theemployee if the annual maximum contribution amounts are exceeded.

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Employer Authorization Signature

Authorized Employer's Signature Name *

Authorized Employer's Title *

Contact Phone Number *

Email Address *

Signature Date * +

Authorized Employer's Signature *

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New Hire Enrollment	New Church to Plan
Employment Transfer	Rehire/Reinstatement
Loss of Coverage	Other (please describe) Other (please describe)

$84/Employee Only	$167/Employee + Child(ren)	$167/Employee + Spouse	$167/Family
N/A (Bronze Plan)