Qsehra plan document template 2025

1. Click ‘Get Form’ to open the QSEHRA application in the editor.
2. Begin by filling out the Applicant Information section. Enter your name, date of birth, SSN, phone number, and complete address including city, state, and ZIP code.
3. Proceed to Employment Information. Fill in your employer's name and address details. Specify your state, phone number, duration of employment, position held, and expected hours worked per week.
4. In the 'I Understand...' section, indicate whether you are applying for a QSEHRA by selecting 'Yes' or 'No'. Confirm your agreement to the terms of the QSEHRA and acknowledge that your employer can change plan provisions at any time.
5. Complete the Spouse and Dependents Covered section by providing names, dates of birth, and SSNs for each dependent.
6. Fill out Individual Health Insurance Policy Information with your insurance company details and annual premium amounts.
7. Finally, specify the amount to be reimbursed for health insurance premiums. Ensure you understand the forfeiture policy regarding remaining HRA account balances.
8. Sign and date both as the applicant and have your employer sign as well before submitting.

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