Welcome to your ICHRA Application!
(takes 5 - 10 minutes to complete)
Desired ICHRA Start Date * Which service are you signing up for? *
Please reference our Complete ICHRA Guide for more information on pricing.
Next - Contact Information You're almost done, let's talk about how your ICHRA will work. ICHRA Setup - Step 1 of 4 - Reimbursements Your Reimbursement Options
Option 1: Premium Reimbursement Only
Option 2: Premium Reimbursement + Pretax**
Option 3: Premium Reimbursement + Pretax + Medical Expenses**
**Additional pretax documents required for Options 2 and 3.
Which ICHRA reimbursement option do you want to offer? * Option 1: Premium Reimbursement Only Option 2: Premium Reimbursement + Pretax Option 3: Premium Reimbursement + Pretax + Medical Expenses Option 4: We're still deciding Previous Next - ICHRA Eligibility ICHRA Setup - 2 of 4 - Eligibility Your Eligibility Options
Info sheets on employee classes
HERE to instantly download our ICHRA Employee Class Quick Guide.
HERE to see our blog post on ICHRA Classes. Do you need assistance with employee classes? * No Yes How many employee classes do you have? * 1 2 3 4 5 or more We're happy to help!
Employee Classes can be challenging. Go ahead and finish your application and we will gladly help you determine an Employee Class strategy during your Welcome Call.
Please describe each employee class. Please provide a detailed outline of your employee class structure, including contribution tiers if applicable, to your Flyte HCM Account Manager. Questions or comments about your ICHRA classes? New hire eligibility period * First of the month following 30 days First of the month following 60 days Other
Select other if your New Hire eligibility is not listed.
Please briefly describe your eligiblity. Previous Next - ICHRA Contributions ICHRA Setup - 3 of 4 - Contributions Your Contribution Options
Generally speaking, there are 2 approaches in deciding what to contribute to your employees ICHRA.
1. Offering a set amount per employee class –
i.e. $250 per Full-time Employee
2. Calculating the flat monthly as an age-banded contribution based on a benchmark plan. –
i.e. 70% of the selected benchmark plan. Mark’s rate for the benchmark plan is $350 and 70% of that is $245, so Mark’s monthly ICHRA contribution is $245. What are you planning to contribute to your ICHRA? * Briefly describe your Fix Contribution structure.
Please include any class the contribution applies to.
Briefly describe your age banded/tiered contribution structure.
Please include any class the contribution applies to.
If you are using an age banded rate you do not need to complete this section. Please upload your age banded documentation in the upload feature during the final step of the application. Acceptable file formats: Excel/csv, Word, PDF.
No worries! It's a big decision.
We can go over this in more detail during your Welcome Call!
Spouse, Dependent and Family Contributions If checked, please briefly describe your dependent contribution strategy. Previous Next - ICHRA Claim Options ICHRA Setup - 4 of 4 - Claim Options Your Claim Options
The 2 minute ICHRA Claims video will help answer your questions about each option below.
Option 1: Direct Pay, by Flyte HCM - premium payments directly to carrier.
Option 2: Annual claim submission - employee files claim once at enrollment for whole year.
Option 3: Monthly claim submission - employees file a claim monthly in order to receive reimbursement.
Which claim option would you like to use? * Flyte Direct Pay Annual Claim Monthly Claim We're still deciding
Note: An additional $2 per enrolled per month and $200 annual fee will be applied for the Flyte Direct Pay service.
We can go over this in more detail during your Welcome Call! Previous Great Job! Next - Finish Up Your Application Agent Information Are you working with a health insurance agent? * No Not yet, but we're looking for one. Yes Agent Email * Agent Phone * ICHRA Plan fee and ongoing reimbursements
Please note that your ICHRA plan and/or administration services cannot be setup until we have received your completed bank authorization.
Total Due Now**
**This is for your ICHRA Plan. Flyte HCM will invoice for any applicable monthly service fees. See Complete ICHRA Guide with pricing for more information.
Please review our terms and conditions of this form. *
Recognition of A Compelling Need For Confidentiality. Flyte HCM LLC "Flyte" and the Client wish to contract together for Flyte to perform Employer Services. Flyte realizes that the Client has a compelling need to maintain confidentiality and further recognizes that a contract with the Client for Employer Services will place Flyte in a position of special trust and confidence with access to confidential information in coordination with fulfilling Employer Services outlined on the Quote.
Consideration. Flyte agrees to not disclose or use, in any manner, any confidential or proprietary information or materials concerning the Client or its operations, unless required to do so in order to conduct the Employer Services Flyte is hired to perform in its ordinary course of business. Furthermore, the Client agrees not to disclose any of Flyte’s Confidential Information that would be provided or obtained during the course of the Employer Services unless express permission to do so is granted by Flyte.
Effect Of Breach. The Parties realize that a breach of this Agreement would cause substantial harm to the operations, business and goodwill of The Parties.
Term and Effective Date. The term of services, as indicated on the Quote, are for one year and may be modified throughout the year as needed or as may be required by law. Flyte agrees to notify Client of any changes, either within or at the end of the term, in writing prior to changes becoming effective. Flyte and Client reserve the right to terminate the effectiveness of this application and Employer Services via written notice to the other party and within at least 30 days termination. This agreement shall not become effective until signed by an authorized representative of the Client.
Client Acknowledgment. As a representative of the Client, I hereby agree; i. to the terms of the Employer Services Quote provided by my Flyte representative and absolve Flyte of any financial or legal recourse arising from any incorrect information provided on this application. ii. That the Client will verify all Client data including legal name, Tax ID, employee data and all other employer data related to the Employer Services, throughout implementation of the Employer Services, and agree to hold Flyte harmless for any incorrect data provided by the Client. iii. Flyte representatives do not have the right to bind Flyte. iv. Additional terms and conditions may apply to the agreement as it pertains to the specific Employer Services chosen, v. that upon signature, the Employer Services listed on the Quote will become a part of this Application. You're all done! Here's what happens next
1. We'll reach out soon to schedule your Welcome Call
2. You'll receive a Welcome Email containing instructions on how to access your portal.
3. Once setup is complete, you'll receive your ICHRA Initial Notice which you employee can use to enroll in their ICHRA and health coverage.
Do you have any questions for us? Is there anything else we need to know that wasn't covered on the application? Thank you for completing this form. You've taken the first step to offering an amazing benefit for your employees.