NEW BUSINESS INFORMATION

If you are a current HealthEquity Client and are looking to renew your existing plan, have recently changed Health Plans, or are inquiring about coming to HealthEquity direct, please initiate this change within the HealthEquity Client Portal.

If you are a new HealthEquity Client or are filling out this form on behalf of the new Client, please complete this form. Once your new business form is received, HealthEquity will begin the steps needed to complete your implementation. You will receive an email requesting a welcome call be scheduled with your implementation manager.

CONTACT INFORMATION

(This is the primary contact who is responsible for signing and authorizing decisions with HealthEquity, if you have another contact or day-to-day contact, please add them within the Onboarding Call Information section)

Primary Contact

Contact type

Phone (area code)

Note: An HRA may provide tax-free benefits only to employees, former employees, retirees, and their spouses or covered tax dependents. Because self-employed individuals are not “employees,” an HRA may not provide tax-free benefits to self-employed individuals (i.e., sole proprietors, partners, and more-than-2% Subchapter S corporation shareholders).

ONBOARDING CALL INFORMATION

Please add anyone that will be making decisions about your HealthEquity account plan design.

(These contacts are in addition to the Primary Contact listed above and will be included in communications regarding onboarding)

Contact name

Contact type

Phone

Total Number of US-based Employees (Full & Part-Time)

Number of benefit-eligible employees

Effective Start Date of Health Plan

Who is your Health Insurance Carrier?

Effective Start Date of Product(s) (when do you expect HealthEquity to start providing services)

Is the health plan Fully Insured or Self-Insured?

Will HealthEquity be receiving a data file from your health insurance carrier or a third party administrator?

Who is your data source?

Additional Comments/Information

Are you working with a Brokerage?

Brokerage/Consultant Company

Brokerage/Consultant City

Brokerage/Consultant State

Do you have the contact Information of Broker/Consultant ?

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Broker/Consultant First Name

Broker/Consultant Last Name

Broker/Consultant Email

Broker/Consultant Phone*

PRODUCTS TO BE ADMINISTERED BY HEALTHEQUITY

Health Savings AccountsFlexible Spending AccountsHealth Reimbursement ArrangementsCOBRA

The following questions are for HSA

Estimated Number of Participants

Are there HSAs to transfer from another administrator?

If the HSA will include services or features offered through a 401(k) administrator or retirement plan provider, please select the provider:

The following questions are for FSA

Estimated Number of Participants

Plan type

use the control or command key to select more than one plan type

The following questions are for HRA

Estimated Number of Participants

Plan type

*Member pays first is only available if integrated claims and enrollment are being sent to HealthEquity by your health insurance carrier.

The following questions are for COBRA

How many employees are enrolled in the Health Plan?

Estimated number of COBRA participants?

Submitter Full Name

Submitter Email

Submitter Phone Number

Product(s)

Contact Information