Plan Data Form: ICHRA & Section 125 Plan Legal Name of Organization (Plan Sponsor) *Mailing Address *City *State/Province *ZIP / Postal Code *Employer's Federal Tax ID Number *0 / 10Entity Type *S-CorporationC-CorporationLLC or PLLCNonprofit Entity or ChurchPartnershipSole ProprietorshipPlan Administrator (Fiduciary), if different from EmployerRelated Employers Included in ICHRA & Section 125 Plan? *YesNoList Employer Name(s) and EIN(s): *Plan Start Date *Please select an optionSelect…January 1February 1March 1April 1May 1June 1July 1August 1September 1October 1November 1December 1Eligibility – Hours *30OtherOther Hours *Eligibility – Waiting Period *0 days30 days60 days90 daysOtherOther Waiting Period *Eligibility – Entry Date *Immediate (next day)First of Following MonthICHRA – Class Structure used? *YesNoType/Amount of Reimbursement: *Monthly or Annual Maximum: *USDBenefits Eligible for Pre-Tax Deduction under Section 125 PlanBalance of Individual Health Insurance Premium Above ICHRA CoverageGroup Dental InsuranceGroup Vision InsuranceHealth Savings Account (“HSA”) bank account contributionsGroup Accident InsuranceGroup Critical Illness InsuranceGroup Hospital Indemnity InsuranceGroup Term Life Insurance (up to $50,000 coverage only)Group AD&D InsuranceGroup Short-Term Disability Insurance (special rules apply)Group Long-Term Disability Insurance (special rules apply)Group Telemedicine BenefitHealth Flexible Spending AccountDependent Care Spending AccountOtherOther Eligible Benefit(s) *Benefits Ineligible for Pre-Tax DeductionGroup Term Life InsuranceGroup Supplemental Life InsuranceGroup Short-Term Disability InsuranceGroup Long-Term Disability InsuranceOtherOther Ineligible Benefit(s) *Does the employer currently offer a Benefit Credit ("Flex Credit") or Waiver Credit? *YesNoBenefit Credit ("Flex Credit") or Waiver Credit *SubmitPlease do not fill in this field.