ConnectYourCare Consumer-Directed Healthcare Administration of HSA, HRA, and FSA plans

New Client Application

Items marked with a are required.*
Employer Information
Company Name*:
Federal Tax ID*:
Plan Effective Date*:
Number of Eligible Employees*:
Business Address*:
City*:
State*:
Zip*:
Mailing Address (if different):
City:
State:
Zip:
Employer Administrator Contact Information The person entered below will receive information via email to continue the set up process.
First Name*:
Last Name*:
Title:
Email*:
Phone*:
Fax:
Contact Information for Person Completing Application (if different from above)
First Name:
Last Name:
Company Name:
Email:
Phone:
Comments/questions: