Brokers Resource Group
HR / Benefit Web Page Set Up
Information
Client Name
_________________________ Phone
# ____________________
Address
____________________________ Fax
# ______________________
____________________________ Web
Address _________________________
____________________________
HR Contact ________________________ Email
____________________
# Employees ____________ Payroll
frequency ____________
Are there different
Classifications for Benefits? 1Yes
1No
Describe _________________________________________________
_________________________________________________
Who is Eligible for
Benefits?
1Full Time, defined
as:___________________________
1Part Time, defined
as:___________________________
1Other________________________________________
Waiting Period
________________
Are the Eligibility &
Waiting Period the same for all benefits? 1Yes
1 No
If No, please explain
________________________________________________________
Please check the benefits
that are offered:
1Medical 1Pension
1Dental 1529 College Savings Plan
1Vision 1FSA
1Life 1EAP
1AD&D 1Long Term Care
1Vol. Life 1Tuition Reimbursement
1Dep. Life 1Vacation
1STD 1Earned Time
1LTD 1Wellness Programs
1401k 1Group Auto/Homeowners
1Other__________________________________________________________________
Medical
Carrier Name: _____________________________
Plan Type:
1HMO
1PPO
1POS
1Other_________________________
Plan Name: __________________________________
Employee Contributions (per pay period)
1Single___________
12-Person___________
1EE+Child___________
1EE+Spouse___________
1Family___________
Dependent Age Limit for Students
123
125
1Other______
Forms to include (Provide
PDF):
1Plan Summary
1Enrollment Form
1Claim form
1Rx Mail Order Form
1Fitness Reimbursement Form
1Other _____________________
Other Important Items to
Note:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Dental
Carrier Name: __________________________
Plan Type:
1DMO
1PPO
1Indemnity (Include Passive
or Blind PPO plans)
1Other___________________________
Plan Name:
__________________________
1Ortho Included 1Ortho NOT Included
Employee Contributions (per pay period)
1Single___________
12-Person___________
1EE+Child___________
1EE+Spouse___________
1Family___________
Dependent Age Limit for Students
123
125
1Other______
Forms to include (Provide
PDF):
1Plan Summary
1Enrollment Form
1Claim form
1Pre-Treatment Authorization
Other Important Items to
Note:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Group Life
Carrier Name:
_____________________________
Plan Name:
_______________________________
Information to be included:
Forms (Provide PDF):
1Plan Summary
1SPD
1Enrollment Form
1EOI Form
1Beneficiary Form
1Waiver of Premium Form
Plan Provisions:
Benefit:
1_____
x Salary
1Flat $_____
Guarantee Issue
Amount______________
Benefit Maximum___________________
Benefit Reduction
Formula___________
Other Plan
Provisions:_____________________________________________________________________________________________________________________________________________________________________________
AD&D
1Mirrors Life Plan Design
Other Plan
Provisions:_____________________________________________________________________________________________________________________________________________________________________________
Voluntary/Supplemental Life
1Same Carrier as Basic Life
1Other Carrier______________________
Information to include:
1Rate or Cost Calculation
1 Benefit Summary
Forms (Provide PDF)
1Enrollment Form
1 EOI Form
1 Beneficiary Form
1Other____________________
Description of Voluntary
Life Coverage Available:___________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
1Spousal Life
Available___________________________________________________________
1Child Life
Available_____________________________________________________________
Other Pertinent Information:
___________________________________________________________________________________
___________________________________________________________________________________
Short Term Disability
Carrier Name: __________________________________
Plan Name:
_________________________________
Forms (Provide PDF)
1SPD
1Plan Summary
1Enrollment Form
1Claim Form
1Other
forms_____________________
Plan Design:
Benefit:__________% of Weekly Salary
Maximum Benefit:___________ per ___________
Elimination Period:
Accident:
11st
Day
18th
Day
1Other__________
Illness:
11st
Day
18th
Day
1Other__________
Duration:
190 Days
16 Months (180 days)
1Other_________
Employee Contributions:
1Are Required 1Are NOT Required
Other Pertinent Information:
___________________________________________________________________________________
___________________________________________________________________________________