enrollment funding managing
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For plan sponsor use only. Not for distribution to the general public.
5. Tools
Where you can find the Employer Guide, the Employee Notification
Reference Guide, and all employer and employee forms including:
Employer forms:
Authorization Agreement for Payment
Employer Contact Change Form
Company Change Form
Employee forms:
All employee forms can be found here and on the member website
under the “Tools & Support” tab.
health & benefit accounts
Authorization agreement for payment
Instructions: Please email or fax the completed form to your Client Service Manager or Business Support Team.
All fields are required.
Payment of employee claims, debit card transactions, and direct deposit payments will be settled directly to the Company’s bank account
(“Account”) at the depositor y financial institution named below (“Depository”).
Company name Tax ID Number (EIN) (xx-xxxxxxx)
Daily reimbursements:
I hereby authorize Bank of America to initiate debit/credit entries to the Account for Reimbursement Claims. (Each business day or
as they occur. The Reimbursement Claims include, but are not limited to, manual/online/debit card transactions for FSAs and HRAs.)
Important* Bank of America’s originating company ID: 6521523496; if filters are not established, ACH errors will occur and could
delay plan processes.
Depository name
Routing number Account number
Monthly fees:
If requesting ACH Pull for monthly fees, please complete the below. I hereby authorize Bank of America to initiate debit/credit entries
to the Account for Fee Funding (Any employer paid fees, including, but not limited to, Set-up Fees and Monthly Fees).
Important* Bank of America’s originating company ID: 6521523496; if filters are not established, ACH errors will occur and could
delay plan processes.
Depository name
Routing number Account number
Employer Portal user change form
Instructions: Use this form to document the designation or updates of an authorized Employer Portal user for your
Employer Group. Please email the completed form to your Client Service Manager or the Business Support Team. Please
allow two business days for processing.
All fields are required.
Step 1: Company information
Company name Company code
To add authorized Employer Portal users, please follow Step 2a: Portal user addition.
To update existing user information, please follow Step 2b: Portal user update.
To remove access for an existing user, please follow Step 2c: Portal user removal.
Step 2a: Portal user addition
Please complete this section to add authorized user(s).
Access role (select one)
Employee Administrator — Manage individual employee data via an online form. May include adding new employees, adding dependents,
updating employee profiles, updating dependents, enrolling employees, adding, updating and removing employee enrollments, updating
advance account balances, and cancelling on hold contributions.
Employee Reviewer — Search for employees and view employee details.
Import Administrator — Import new files, view the import queue, take action on files in the import queue and access the exception log to
view errors within import files or update errors and resubmit new files. Schedule recurring contributions, cancelling on hold contributions.
Import Monitor — View the import queue and access the exception log to view errors within import files.
Informer — View plans and access resources.
Report Manager — Request, view, remove reports and view employer dashboard.
Report Reviewer — View scheduled reports and employer dashboard.
New user information
Name
Email address Phone number
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