WRAP Document Application

EMPLOYER CONTACT INFORMATION

Legal Name of Organization: ___________________________________________________________________________

Federal Employer Tax ID #: _______________________ Date Incorporated/Organized: ___________________________

Mailing Address: ____________________________________________________________________________________

City: _________________________________________ State:____________________ Zip:_______________________

EMPLOYER CONTACT INFORMATION

Contact Name: _________________________________ Contact Email:________________________________________

Phone (w/Ext.):________________________________ Fax #:_______________________________________________

BROKER CONTACT INFORMATION

By checking this box, you authorize to disclose the information provided in this application to the Broker

identified below. You understand that O.C.A. is authorized to share this information with the named broker

until you have provided written notice to OCA of any changes.

Broker Name: ________________________________ General Agency Name: _______________________________

Phone (w/Ext.):_______________________________ Broker Email:________________________________________

INVOICE REMITTANCE INFORMATION (Complete if Someone other than Employer is Responsible for Invoicing)

Invoice Contact: ____________________________________________________________________________________

Complete Mailing Address: ____________________________________________________________________________

Phone: _______________________________________Email:________________________________________________

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Group Comprehensive Medical (i.e. Horizon HSAc EPO) (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ________________

This benefit is offered through the employer’s cafeteria plan.

Group Comprehensive Medical (i.e. Horizon HSAc EPO)

(Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ________________

This benefit is offered through the employer’s cafeteria plan.

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Dental (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ________________

This benefit is offered through the employer’s cafeteria plan.

Dental (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ________________

This benefit is offered through the employer’s cafeteria plan.

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Vision (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

Vision (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Group Term Life Insurance for employees (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

Group Term Life Insurance for employees (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Identify the insurance carrier that issues the policy: ____________________

What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Group Supplemental Life Insurance for employees (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

Group Supplemental Life Insurance for employees (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Group Dependent Life Insurance for Spouse and/or Dependent Child (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Identify the insurance carrier that issues the policy:____________________

What are the eligibility requirements for this benefit option? __________________________________________ When does coverage begin if elected? ____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Short Term Disability Benefits (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Employees are required to contribute towards the cost of the coverage.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________

What are the eligibility requirements for this benefit option?_________________________________________

This benefit is offered through the employer’s cafeteria plan.

.

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Short Term Disability Benefits (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Employees are required to contribute towards the cost of the coverage.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________

What are the eligibility requirements for this benefit option?_________________________________________

This benefit is offered through the employer’s cafeteria plan.

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Long Term Disability (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________

What are the eligibility requirements for this benefit option?__________________________________________

When does coverage begin if elected?____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Long Term Disability (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________

What are the eligibility requirements for this benefit option?__________________________________________

When does coverage begin if elected?____________________________________________________________

This benefit is offered through the employer’s cafeteria plan.

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Health Reimbursement Arrangement (Please provide summary of benefits and plan document if available)

Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________

What are the eligibility requirements for this benefit option?__________________________________________

When does coverage begin if elected? ____________________________________________________________

If there are more than two options, please provide the relevant information with respect to each option on an

attachment to this application.

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Health FSA (General Purpose) (Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Identify the claims administrator:_________________________________________________________

This benefit is funded through a trust.

What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected?____________________________________________________________

Limited Purpose Health FSA

(Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Identify the claims administrator:_________________________________________________________

This benefit is funded through a trust.

What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________

Dependent Care FSA

(Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Identify the claims administrator:_________________________________________________________

This benefit is funded through a trust.

What are the eligibility requirements for this benefit option?__________________________________________ When does coverage begin if elected? ____________________________________________________________

Benefits to wrap…

Benefits You Desire to Offer under the Wrap Plan: Please provide the information with respect to benefit option

identified below that you desire to aggregate into a single plan under the wrap document.

Other ________________________________________________ (Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________

What are the eligibility requirements for this benefit option?__________________________________________

When does coverage begin if elected? ____________________________________________________________

Other _______________________________________________ (Please provide summary of benefits and plan document if available) Current plan or policy year: ________/__________/__________ Total Number of Participants in this benefit as of the first day of the last plan year or policy year: _______________

Self-funded. If self-funded, identify the claims administrator:_______________________________

This benefit is funded through a trust.

Fully insured: If fully insured, identify the insurance carrier that issues the policy:__________________________

What are the eligibility requirements for this benefit option?__________________________________________

When does coverage begin if elected? ____________________________________________________________

Participating Employers: Please Identify all of the employers whose employees participate in one or more of the benefits identified above, the specific benefits in which their employees participate, and whether they are a member of the same “controlled group” or not.

Employer name

Identity of benefits in which the

employer’s employees participate

Whether or not the employer is in the same

controlled group as the plan sponsor

The employer’s employees

participate in all of the benefits

identified above.

The employer’s employees only

participate in the following

benefits:

The employer is a member of the same

controlled group as the plan sponsor.

The employer’s employees

participate in all of the benefits

identified above.

The employer’s employees only

participate in the following

benefits:

The employer is a member of the same

controlled group as the plan sponsor.

The employer’s employees

participate in all of the benefits

identified above.

The employer’s employees only

participate in the following

benefits:

The employer is a member of the same

controlled group as the plan sponsor.

The employer’s employees

participate in all of the benefits

identified above.

The employer’s employees only

participate in the following

benefits:

The employer is a member of the same

controlled group as the plan sponsor.

This page should be completed for “Controlled groups” only. To view the definition of a controlled

group, please go to http://www.irs.gov/pub/irs-tege/epchd704.pdf

Important Information

You should keep in mind. What are the pros and con’s of an “Umbrella Wrap”? Few would dispute that ERISA-covered plans are subject to a certain amount of required compliance baggage. Among other things, each ERISA plan is required to: be maintained pursuant to a formal plan document; be described to participants through a summary plan description; have assets maintained in an ERISA-compliant trust, and file an annual Form 5500 (when applicable) each year. The theory behind an Umbrella Wrap is that the cost of the ERISA infrastructure can be spread across many benefits resulting in less costly administration for each benefit that is provided. Since ERISA does not prescribe a specific plan design for welfare benefits, the plan sponsor is free to wrap together one or more other wise unrelated welfare benefits into an Umbrella Wrap document. That said, plan sponsors may unwittingly increase their Form 5500 obligations when adopting an Umbrella Wrap. For example, an employer that offers dental coverage with 70 participants and vision coverage with 40 participants (only 10 of whom also have dental coverage) may subject itself to Form 5500 requirements for the first time when the benefits are wrapped (i.e., because there are now 100 participants in a single plan). Likewise, an employer that offers unfunded benefits (such as a health FSA or HRA) that may otherwise be exempt from ERISA’s audit requirements may subject the unfunded benefits to the audit requirement when the benefit is “wrapped” with a funded benefit (e.g., primary health coverage).

Fee Information

By signing this document you are stating that you have had an opportunity to review this document in its entirety.

Additionally that you agree to the terms and conditions set forth by O.C.A. Benefit Services.

______________________________________________________________________________________________

Employer Signature Date

$650 Annual Fee (The renewal fee will be reduced to $300 for preparation of Summary of Material Modification

(SMM). If new Plan Document and SPD is required, O.C.A. will revert back to the annual fee of $650.)

o Includes Wrap Document and Summary Plan Description

o Any mid-year changes are included at no additional cost. (Client must notify O.C.A of any changes)

o Service automatically renews each year and is subject to the annual fee

o Client may cancel services 30 days prior to the renewal. A written notice to O.C.A. is required.