ICHRA New/Renewal Case Install Form

ICHRA Case Installation
Case Status*

NewRenewal
Company Name*
Company EIN Number*
Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Type of Business*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Contact Name*

First NameLast Name
Company Contact Position (Business Owner, HR, Administrator, etc.)*
Company Contact Email*
example@example.com
Is this an ICHRA takeover?*

YesNo
Number of Eligible Employees*
Payroll Frequency*
Employee Waiting Period*
Plan Year Effective Date*

MonthDayYear
Date
Plan Year End Date*

MonthDayYear
Date
What date do you want the enrollment portal opened?*

MonthDayYear
Date
What date do you want the enrollment portal closed? *

MonthDayYear
(Please note that you need to close the site by the 10th of the month for the 1st of the following month effective).
Premium payments to be funded by:*
Are there different classes that have different benefits offerings or employer contribution amounts? *
Please select ALL employee classes IF the benefits offerings, employer contribution, or employer banking differs.*
If specific class names, list each on a new row.
If the company has different classes that recieve different benefit offerings or employer contributions, please note: each class of employees will have their own company code to register with to enroll. The HR/admin will receive one login to manage all.
Employer Contribution

Employer contributions for ICHRA may be revised at the annual open enrollment. For renewal, please review your current contributions. If there are no changes, please indicate below.
For renewal, will there be changes to the employer contribution?
Employer Contribution Strategy*

Flat Dollar AmountPercentageACA Contribution (3:1 Ratio)No Employer Contribution
Enter the base plan and plan ID:
Enter the flat dollar amount:*
Ex. $50 per employee only
Enter the percentage:*
Please click HERE to view the Employer Contribution Template that we will need to upload to the GoWell portal.
Upload the Employer Contribution Table here!

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For 3:1 Ratio / ACA contribution, enter the name of the base plan, plan ID number, and employee's maximum contribution:*
Ancillary/Voluntary Benefit Offerings
Are you offering any other benefits besides ICHRA?*
Select all the benefits you will be offering to the group.*

DentalVisionAccidentCritical IllnessHospital Indemnity/GAPShort-Term DisabilityLong-Term DisabilityBasic LifeVoluntary Life
Enter the Employer's Contribution for Dental. If none, put N/A.
Enter the Employer's Contribution for Vision. If none, put N/A.
Enter the Employer's Contribution for Accident. If none, put N/A.
Enter the Employer's Contribution for Critical Illness. If none, put N/A.
Enter the Employer's Contribution for Hospital Indemnity/GAP. If none, put N/A.
Enter the Employer's Contribution for Short-Term Disability. If none, put N/A.
Enter the Employer's Contribution for Long-Term Disability. If none, put N/A.
Enter the Employer's Contribution for Basic Life. If none, put N/A.
Enter the Employer's Contribution for Voluntary Life. If none, put N/A.
Upload all plan summaries and rates here.

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Employee Communication
Email Communication (Free service - sent from GoWell)*

Yes (Upload a census below to include employee names and email addresses)No (Our company will manage sending out internal emails)
Text Communication (Additional service cost listed below)*

Yes (Upload a census below to include employee names and mobile numbers)No
Text Message Pricing - Per Round*

0-25 Employees - $4025-50 Employees - $7550-75 Employees - $11575-100 Employees - $150100-200 Employees - $300200-500 Employees - $750500-1000 Employees - $1,500No Text
How many rounds of text are desired? *
Total Cost for Text Message Service
Employee Census*

Employee name, phone number, email address
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Company Logo

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Company Notes
Broker Information
Broker Agency Name*
Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Broker Name*

First NameLast Name
Broker Email*
example@example.com
Broker Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Broker NPN*
Enter the total ICHRA PEPM Admin Fee.*
This will be charged monthly to the employer group via ECHO.
Who is your GoWell Sales Rep?*
Compliance Services

Annual charge billed by GoWell to the employer group
Compliance Services (Annual Cost)*

ICHRA Compliance Doc $500 (All ICHRA groups must have an annual ICHRA compliance doc on file)Section 125 Doc $250Wrap Doc $250Compliance Bundle (ICHRA Compliance, Section 125, Wrap) $950Nondiscrimination Testing $500No Compliance Docs Needed
Add-On Services

Billed by GoWell to the employer group
Optional Services*

Form 5500 $450 (Annual cost)1094 $500 (Annual cost)1094 $500 + $7.95/per form (if mailing is needed)1095 $6/per form1095 $7.95/per form (if mailing is needed)ICHRA Enrollment Processor (submissions only) $5 PEPM (This will be in addition to the PEPM admin fee)COBRA - Administered by Anuvi ($1 PEPM Per Enrolled)Ransomware Identity Theft Protection ($9.95 PEPM)No Additional Services Needed
Are you interested in adding GoWell's Ancillary Products?*
Here is a list of our partners for Dental and Vision coverage. Please select any of the below that you are interested in getting a quote for. (Must upload a census in the dropbox below for a quote to be completed)

MetLife/VBADominion/VSPDelta/VSPBeam Dental/VSPCombined InsuranceNot Interested
Upload census here if you're interested in ancillary quote from one of the above carriers.

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Employer Group Bank Information

This account will be used to set up the employer's HRA account with ECHO to fund the ICHRA.
For renewal, is the employer's banking changing? *
Employer Bank Name*
Employer Bank Account Type*
Employer Routing Number*
Employer Account Number*
Employer HRA Account Setup

This account will be used to automatically fund the employer’s HRA for monthly ICHRA premium payments.
Initial Premium Amount
Enter the total premium payment due for the first month (can be estimation per quote).
Reserve Amount
Enter the amount you would like to reserve in your HRA to fund any new hires / enrollment changes throughout the year.
Total Single Binder Payment
Sum of the premium and reserve. This amount will draft on the date you
Single Binder Draft Date

MonthDayYear
Initial Draft Date must be by the 10th of the month prior to effective date.
Employer Group Billing Point of Contact
For rewewal, did the group's billing contact change?*
Billing Contact Name*

First NameLast Name
Billing Contact Title*
Billing Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Billing Email*
example@example.com
ECHO - ACH

Terms and Conditions
Employer Group, on its own or through its Administrator, hereby authorizes ECHO Health, Inc., hereinafter called ''ECHO," to initiate debit entries for approved Individual Healthcare Coverage Reimbursement Arrangement (''ICHRA'') Payments and to initiate, if necessary, credit entries and adjustments for any debit entries in error, refunds received for Employer Group's account indicated below at the depository named below, hereinafter called ''Depository." The authority granted through this agreement authorizes ECHO to provide the information to ECHO's clearing bank, enabling ECHO to provide its services. ECHO provides electronic payment consolidation services for benefit plans and employer groups and does not provide money transmission services. ECHO is not a bank, money transmitter, or Money Services Business (''MSB''), and ECHO does not offer banking or MSB services as defined by the United States Department of Treasury.

Employer Group does hereby agree and guarantee that the required funds will be on deposit in the account specified above within twenty four (24) hours of its approval and are available for the sole purpose of allowing ECHO to make ICHRA payments on its behalf. Further, funds, once available, will be withdrawn from this account and will be deposited in an account established by ECHO at ECHO's clearing bank. Failure to fund such account in such timely manner may result in a delay of payments. Any fines or penalties assessed to the account established by ECHO will be the responsibility of Employer Group.

Continued failure to fund such account may result in a loss of service for the payment of ICHRAs.

Employer Group also agrees to permit Echo to open one or more For the Benefit of (''FBO'') accounts to facilitate the payment of premiums for employees. These accounts will be opened by ECHO under ECHO FBO Employer Group FBO Employee and will have the specific purpose to only pay the premiums owed by the employee. Notwithstanding the forgoing, Enployer Group acknowledges and agrees that Employer account may be subject to a monthly administrative charge payable to Administrator. The administrative charge will automatically be deducted from Employer account on a monthly basis independent of any premium payments. The employee will have no claim to these funds, and if premiums are not paid to the carrier, they will be returned to the Employer Group for disposition.

Employer Group also allows ACH from GoWell Benefits Inc. for ICHRA compliance fees, platform/tech fees or PEPM fees.
By completing this ICHRA case installation form, the ECHO ACH form is also populated. GoWell will use the completed ECHO ACH form to establish the HRA account on behalf of the employer group.
Date*

MonthDayYear
Name of signor*

First NameLast Name
Broker Signature*

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Employer Signature

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ICHRA Case Installation

Employer Contribution

Ancillary/Voluntary Benefit Offerings

Employee Communication

Broker Information

Compliance Services

Add-On Services

Employer Group Bank Information

Employer HRA Account Setup

Employer Group Billing Point of Contact

ECHO - ACH