Health Reimbursement Arrangement Setup Checklist Form
Complete this checklist to ensure all essentials are in place for setting up your Health Reimbursement Arrangement (HRA).
Organization Name
*
Primary Contact Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Plan Year Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Plan Administrator
*
Type of HRA
*
Please Select
Integrated HRA
Qualified Small Employer HRA (QSEHRA)
Individual Coverage HRA (ICHRA)
Excepted Benefit HRA (EBHRA)
Other
Eligibility Criteria
Funding Source
*
Please Select
Employer-funded
Other
Have all required supporting documents been prepared?
*
Yes
No
Additional Notes (optional)
Submit Checklist
Should be Empty: