The Employer maintains a Plan Document; if anything in this document conflicts with the Plan Document, then the Plan Document controls.

Rev. 08/2011

HRA 100-10

Add

Remove

Relationship to Participant:

Spouse

Domestic Partner

Child

SSN: _______________________

Please check all that apply:

Last Name: __________________________________________________ First Name: ________________________________

(MI): ____

End Stage Renal Disease (ESRD)

Gender:

Male

Female

Date of Birth: ______ / ______ / ______

Disabled

Medicare Health Claim Number (HICN): ________________________

(if applicable)

Effective Date of HRA Coverage: ______ / ______ / ______

Current Medicare Beneficiary

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - -

Add

Remove

Relationship to Participant:

Spouse

Domestic Partner

Child

SSN: _______________________

Please check all that apply:

Last Name: __________________________________________________ First Name: ___________________________________

(MI): ____

End Stage Renal Disease (ESRD)

Gender:

Male

Female

Date of Birth: ______ / ______ / ______

Disabled

Medicare Health Claim Number (HICN): ________________________

(if applicable)

Effective Date of HRA Coverage: ______ / ______ / ______

Current Medicare Beneficiary

C. E MPLOYEE C ERTIFICATION

Return signed form to your employer.

I have received and read the printed material which explains my plan and my options under it. I understand that any expenses paid under this plan must be eligible expenses as governed by Internal

Revenue Service (IRS) regulations, must be for services provided for me or a qualifying individual and must not be reimbursed from any other source. I also understand that if I or my spouse has a

Health Savings Account (HSA), contributions cannot be made to the HSA while there is coverage under a Health Reimbursement Account (HRA).

I understand that Federal law requires financial institutions to obtain, verify and record information that identifies each person with an account. I also understand that I may be required to provide

identifying information (e.g. social security number, address and date of birth) when making inquiries about my account. I understand that any personal information obtained will not be shared with

anyone, including non-affiliated third parties, except as permitted by law. I verify that the information detailed above is true and accurate. I understand that certain information being requested is

necessary to comply with the mandatory Section 111 reporting and will be sent to The Centers for Medicare & Medicaid Services (CMS).

If a Beniversal® MasterCard® Prepaid Card is associated with my HRA:

•

I authorize the issuance of a Beniversal MasterCard by a bank chosen by Benefit Resource. I agree to use this card only for eligible medical expenses under the plan for me or a qualifying

individual and to be bound by all provisions of the Beniversal

Cardholder Agreement

and

My Beniversal Use of Card Promises

sent to me with my card. Furthermore, I understand that if my

Beniversal Card is used for expenses other than eligible medical expenses or if I violate the terms of the

Agreement

, my account may be suspended and I will reimburse the plan for the expenses. I

authorize my employer to deduct any non-approved expense directly from my paycheck on an after-tax basis. I also authorize expenses for replacement cards and paper followup requests to be

deducted from my account balance as needed.

•

Since the IRS requires that certain purchases made with the Beniversal Card be verified for eligibility, I agree to acquire and retain sufficient documentation for any expense paid with the card

and to submit such followup documentation to Benefit Resource upon request.

Signature: _______________________________________________________________________________________

Date: _____ / _____ / ______

D. E MPLOYER S ECTION

(to be completed by the employer)



Effective date of enrollment/change:

_____ /_____ /_____



Please select only one option:

New Enrollment: funding amount _________________

per plan year

Other_______________________________

Termination

Resignation

Retirement

Change in hours

Other_______________________________________



Health Insurance Coverage Code: ___ ___ ___ ___ ___ ___

This information is required for Beniversal Cards. The six digit code must match a code on your Group Insurance Form. Note: If