Required Health Plan Contribution Report

ERISA rules require that employers track, and the Unitarian Universalist Association (UUA) report, the dollar amount of Health Plan premiums paid by employers as well as the dollar amount paid by employees. 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.

Use this secure Health Plan Splits Form to report the split monthly premium between employer and employee contributions.

Important Points

  • Only include the premium amounts for the UUA Heath Plan; do not report any premiums associated with Dental, Life, or Disability coverage.
  • Show only the dollar amount that the employer contributed, and the dollar amount each employee contributed for UUA Heath Plan premiums. Report only monthly premiums, not specific payroll amounts.
  • The total for employer and employee contributions must add up to the monthly billed health premium for each person.
  • All health plan participating groups must complete this on a monthly basis.
  • You cannot save the online form and return to it later. The form must be completed and submitted in one sitting.
  • Before hitting "Submit", please print a copy for your records.