Switching to DR Associates Ltd. from another provider? Here’s what we need:

Your Fiscal Year-End*

The Anniversary Date of your old plan, ie. the date your employees get their new Annual Limit each year*

(Ideally, this will also be your new plan Anniversary Date, so your employees don’t gain or lose any months of coverage.

The Effective Date you would like your new plan with us to start*

List of Covered Employees

Covered Employee*

Annual Limit*

Unused Portion*

List of covered employees above is up to date as of this date:*

Does your current plan allow a “rollover” or “carry forward” of unused dollars from one benefit year into the next on the Anniversary Date?

Yes

No

If a rollover or carry forward is allowed, is only the previous benefit year’s unused portion carried forward, or are multiple years of unused benefit allowed to accumulate?

Just the previous year

Multiple years

Do you have a Probation Period before new employees can be part of your Health Spending Account plan?

Yes

No

If yes, how long? (in months)

Do you Pro-Rate their benefit dollars from the date they finish their probation period until the Anniversary Date?

Yes

No

Form SWITCHING TO DRA

Switching to DR Associates Ltd. from another provider? Here’s what we need:

List of Covered Employees