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800-929-9213

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QSEHRA Employer Enrollment Form

Complete the form below to get started with offering a QSEHRA to your employees.

If you have any questions, contact our insurance team at (800) 929-9213 or [email protected].

QSEHRA Employer Enrollment Form

Employer Information for Plan Documents

Address
City
State/Province
Zip/Postal

Effective Date

You can go as far back as the beginning of the current month

Plan Year

The first plan year will be: *

Waiting and Eligibility Requirements

Employees are eligible to participate in the plan on: *

Plan Options

Annual benefit limit: *
Will the funds be available: *
Will the plan reimbursement be for: *
Will the plan carry over unused funds at the end of the plan year? *

Household Employee Benefits & Insurance

Talk to an Expert

Our employee benefits experts are available to discuss your needs and help you get started with a Health Reimbursement Arrangement or other benefits.

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(800) 929-9213
Mon – Fri 8:30 am – 8 pm ET

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