MaxStaff offers online administration system for FSA, DCA, HSA and HRA client administration using mbi Debit Cards. These debit cards grant instant access to account dollars. Our system allows online employee self service (ESS) for enrollment and account tracking, making ongoing plan administration and servicing more convenient for employers.
  1. Legal Name of Company Sponsoring Plan:
  2. Business Entity Type:
  3. Principal Business Activity:
  4. Federal Employer Identification Number:
  5. Contact Person:
    Title:
  6. Street Addresses (No P.O. Boxes):
    City:     State: Zip:
  7. Phone: Fax: E-Mail:
  8. Effective Date
    This HRA or FSA Plan will be:
    A)     A new plan effective as of (date):
    B)     An amendment and restatement of a previously established Section 125 Plan of the employer.
        1) This amendment and restatement is effective as of (date):
        2) State the effective date of the original plan:
        3) State the plan number:
  9. Plan Year End: if applicable
  10. Employer's Principal Office - This HRA or FSA Plan shall be governed under the laws of the:
  11. Benefits - The benefits selected below shall be included in the HRA or FSA Plan:
    Medical Expenses not covered by insurance.
    Health and other (select coverages below):

    Health Insurance
     Dental Insurance
    Vision Care Insurance
    Mass Transit and Qualified Parking
    Accountable Education Expenses
     Other (specify):
  12. Legal Name (s) of Affiliated Company (ies) that will be covered by this plan:
  13. Total number of Employees participating in the Medical Plan:  
  14. Payroll is Prepared
     In House
     Other:
  15. HRA Plan. A one time set up fee applies per employee participating in the Company sponsored Medical Plan.  (Minimum set up fee $750 or $15 per eligible employee, which ever is higher)

    FSA Plan

    Monthly Recurring Charge: $     per participant (s), charges includes HRIS.

    Consultant Name:

    Consultant E-Mail:
  16. New plan set-up is delivered via your company's web site, and enrollment is done by your consultant.

Comments: