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:
___________________________________________________________________________________
___________________________________________________________________________________
Long Term Disability
Carrier Name:
___________________________________
Plan Name:
__________________________________
Information to be included:
1SPD
1Plan Summary
Forms (Provide PDF)
1Enrollment Form
1Claim Form
1Other forms_____________________
Plan Design:
Definition of Disability:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Elimination Period:
130 days
160 days
190 days
1180 days
1Other___________
Benefit Duration:
1To Age 65
1 SSNA
1 Other
Benefit Replacement
Level:___________% of Salary per ___________
Maximum benefit:
$___________per ___________
Other Pertinent information:
___________________________________________________________________________________
___________________________________________________________________________________
Retirement Plan
Plan Type:
______________________________
Plan Name: ______________________________
Provider:_______________________________
Administrator (if different
from Provider):_________________________________
Employee Contributions
Allowed: between_______ % and _______% of pay Before Taxes
Are After Tax Contributions
allowed?
1Yes
1No
If Yes, what amount? _________________
Is there a Company Matching
Contribution?
1No
1Yes
If Yes, Please explain:
______________________________________________________
________________________________________________________________________
________________________________________________________________________
Vesting
Schedule:_____________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Number of Investment Funds
Offered: ___________
Information to be included
(Provide PDF):
1Enrollment Kit
1Listing of Investment Option
Forms (can be pulled from
Provider site)
1Enrollment Form
1Beneficiary Designation
1Change Form
1 Other Forms______________________
Eligibility Requirements if Different
from other programs:_____________________________________
___________________________________________________________________________________
Plan Entry
Dates:_____________________________________________________________________
___________________________________________________________________________________
Flexible Spending Accounts
Plan Name:
_______________________________
1Health Care
1Dependent Care
1Transportation - Transit
1Transportation - Parking
Maximum allowable
Contribution $______________
Flex Administration
Provider:_______________________
Other Information to include
(PDF):
1 Plan documents
1Brochures
Forms:
1 Enrollment
1 Reimbursement Request
1Direct Deposit
1 Other
Human Resources
Additional information
related to Human Resources can also be added to this site if you would like to
provide the information. In the past
clients have included some of the following information: (Please check the applicable
box if you are looking to include this information by providing us with the
necessary information in electronic format.)
1 EE Handbook 1 Co Directory 1 New Hire Orientation
1 Policy Manual 1 Holiday Schedule 1 Introduction
1 Announcements 1 Time Sheet 1 Company History
1 Tax Forms 1 Direct Deposit 1
Handbook
1 I-9 Form 1
Emergency Contact 1 Payroll Summary
1 W-4 Form 1 Payroll Schedule 1 Direct Deposit Forms
1 Expense Reports 1 Email Directory 1 Tax Forms
1 Address Change 1 Non-Disclosure
1 Other ______________________
1 Other_______________________________