iPlanRx — Employer Onboarding Document Generator

📋 Company Information

Client Legal Name *

Client DBA Name

Tax ID / EIN *

Corporate Structure

Mailing Address *

City *

State *

ZIP Code *

Phone

Fax

Website

👤 Administrative Key Contact

Contact Name *

Contact Email *

Contact Phone *

🏥 ICHRA Plan Details

Plan Name *

Typically: [Company Name] ICHRA Plan

Plan Number

Administrator *

Plan Year Start (Month/Day) *

Plan Year End (Month/Day)

Original Plan Adoption Date *

Amended / Restated Effective Date *

Requested Effective Date *

Notice Date

Date printed on the 90-Day Notice

💰 Eligibility & Contributions

Eligible Employee Class *

Custom Class (if selected above)

Waiting Period *

Spouse & Dependents Eligible?

ICHRA Contribution Amounts *

Type:

Enter the maximum annual ICHRA dollar amounts per coverage tier

Self-Only

Employee + 1

Family

Self-Only (for Exchange)

Amount the Exchange uses for affordability

🏢 Plan Administrator

Same as Company Information

Administrator Name *

Often the employer name, or a TPA

Administrator Phone *

Administrator Address

📝 Additional Information

Governing State Law

Leave blank to use company state

Number of Employees

Schedule A — Affiliated Employers

Agent for Service of Legal Process

⚖️ Compliance & Regulatory

Applicable Large Employer (ALE)?

Under the ACA, employers with 50+ FTEs

Subject to Federal FMLA?

Subject to COBRA?

Subject to HIPAA Privacy/Security?

COBRA Details

COBRA Vendor Same as Plan Sponsor?

COBRA Vendor Name

COBRA Vendor Phone

COBRA Vendor Address

PHI Access Designation

🏛️ Third Party Administrator (TPA)

Does a TPA administer plans?

TPA Name

TPA Phone

TPA Address

🔴 ICHRA-Specific Details

Reimbursement Scope

Contribution Frequency

Age-Based Contribution Amounts?

Debit Cards Available?

Pro-Rate Contributions for New Hires?

Carryover Feature?

Carryover Limit

Maximum Carryover Amount

Claims Runout Period

Time after plan year end to submit claims

Runout Period for Terminated Employees

Former Employee Eligibility

Participation Start Trigger

🔵 POP / Section 125 — Specific Details

POP Plan Name

Auto-populated from Company Name. Edit to override.

Enrollment Type

Midyear Election Changes

HSA Pre-Tax Contributions?

HSA Details

Employer Also Contributes to HSA?

Employer HSA — Individual/Year

Employer HSA — Family/Year

HSA Election Change Frequency

Opt-Out Benefits Offered?

Opt-Out Benefits

Opt-Out Type

Opt-Out — Employee Only/Year

Opt-Out — 2-Person/Year

Opt-Out — Family/Year

🟢 ERISA Wrap — Plan Features

Wrap Plan Name

Wrap Plan Number

Section 125 / Cafeteria Plan Name

Contractual Lawsuit Time Limit?

Lawsuit Time Limit (months or years)

Wrapped Plan Features / Benefits

Add each benefit plan that will be wrapped (medical, dental, vision, life, disability, etc.)

🤝 iPlanRx Sales

Primary Sales Rep *

Split Case?

Split Case Details

Secondary Sales Rep

Primary Rep Split %

Secondary Rep Split %

⚙️ Integration Settings

Configure your Google Sheet logger and AgencyBloc connection. Settings are saved in your browser only.

📊 Google Sheet Logger

Apps Script Web App URL *

Deploy the Apps Script from Google Drive and paste the Web App URL here. Intake data is saved automatically when you generate the checklist.

📤 AgencyBloc Connection

Cloudflare Worker URL *

Deploy the provided Worker script to Cloudflare and paste its URL here.

AgencyBloc User ID Mapping

Find User IDs in AgencyBloc: Settings → Users → click each user → check the numeric ID in the browser URL bar.

🏢 Admin Team User ID

Handles doc prep tasks

💰 Sales Team User ID

Tom — client-facing sales steps

🏥 Service Team User ID

Jason — carrier enrollments

📣 Outreach Team User ID

Ben — outreach and service support tasks

📋 Compliance User ID

HIPAA/regulatory tasks