Note: You may ignore this form if ALL of your employees have only Life, Dental or Disability insurance.
ERISA rules require that Employers track, and the UUA report, separately, the amount of UUA HEALTH PLAN premium funded by an Employer and the amount paid by Employees for themselves and their dependents. Our Health Plan auditors review this information and may request detailed payroll documentation from non-reporting Employers in order to satisfy Department of Labor filing requirements. ERISA and Department of Labor rules require that you:
Complete this form annually.
Complete this form for HEALTH PLAN premium contributions ONLY.
Do NOT include any information for Life, Dental or Disability payments.
Check the YES box if you are on COBRA or billed as a self-employed person.
Show the dollar amount that the Employer contributed and the dollar amount each Employee contributed for HEALTH PLAN PREMIUMS ONLY.
The total for each Employee should match the amount billed for the year for the UUA Health Plan.
Note: You can save this form and return to it later. In addition, you may come back and correct errors prospectively. A copy of your form will be emailed to you upon submission.