BASIC HSA Enrollment

Online Proposal Data Entry

?Employer Name:

?Employer Contact:

?Employer Contact Email:

?Agent Name:

?Agency Name:

Choose your BASIC Benefits Consultant:

?Current Plan Name:

?Total Monthly Premium Current:

?HDHP Name:

?Total Monthly Premium HDHP:

Percent of Current Premium Paid by Employer:

Percent of HDHP Premium Paid by Employer:

?Total Number of Employees:

?Estimated Number of HSA Participants:

?Number Singles:

?Number Families:

HDHP Plan Deductibles

?Single:

(must be >= $1100)

?Family:

(must be >= $2200)

Estimated Employer HSA Contribution

1st Year

?Single:

?Family:

HSA Pricing

?PEPM:

3.35

?Plan Year:

?Capped monthly value of Employer HDHP premium and Contribution amount:

HSA Audit Protection

?Number Audit Protection Kits estimated at $60 per kit.
(optional - see help screen for details):

?Percent employer will pay for each kit:

?Estimated Premium Increase by Percentage	1st Year	2nd Year	3rd Year	4th Year
?HDHP	%	%	%	%