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Why offer HSA Deductions in a Section 125 Plan?
Purchaser Information
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The "Purchaser" is the person placing the order, (insurance agent, accountant, payroll co. contact, etc.) not necessarily the "Employer" for the plan document. Enter the name of the person that you would like us to contact if we have any questions about the order. This could also be an employee of the "Employer" such as the HR Director or clerical person, etc.
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The "Purchaser" is the person placing the order, (insurance agent, accountant, payroll co. contact, etc.) not necessarily the "Employer" for the plan document. Enter the name of the person that you would like us to contact if we have any questions about the order. This could also be an employee of the "Employer" such as the HR Director or clerical person, etc.
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The "Purchaser Company" is the Company placing the order, not necessarily the Company paying for it or the "Employer" for the plan document. Enter the name of the Company where the "Purchaser" is employed. Do not use any hyphens as they will stop the form from working. Add a note below if you omitted hyha en in the company name.
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We normally ship the document to the Purchaser if the binder option is chosen. If this is NOT the address that you would like the plan document shipped to, please indicate the correct shipping address on the credit card payment form and/or in the Notes section at the bottom of this order form.
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City where we ship the plan document, if binder option is chosen.
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12345-
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Example: (123)456-7890
Example: 1234
Example: (123) 456-7890
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We normally email the PDF copy of the plan document to the Purchaser's email. If this is not the email for delivering the plan document please indicate the correct delivery email in the Notes area at the end of this order form.
Purchaser Name

The "Purchaser" is the person placing the order, not necessarily the "Employer" listed in the plan document, or the person paying for it. Enter the name of the person that you would like us to contact if we have any questions about the order (i.e. Accountant, Agent, TPA, Payroll Company, or HR Mgr., etc.).

Employer Information for Plan Documents
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Normally the business owner or Key Employee. Please enter the first name of the person authorized to sign the plan document.
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Normally the business owner or Key Employee. Please enter the last name of the person authorized to sign the plan document.
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Enter the legal name of the Employer, EXACTLY as you would like to see it in your Plan Document. Do not type all in upper case or all lower case; check your spelling and punctuation. If using a DBA, or the legal name includes a DBA, please include in the Notes the full legal name and which name you would like us to use as the common name in the plan document.
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Please enter the physical address of the Employer.If you have a P.O. Box or alternate address that you would like the document mailed to, this may be entered in the Notes or on the credit card payment form.
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Example: (123) 456-7890
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Example: (123) 456-7890
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Indicate in the Notes area below if you would like to have the plan document PDF copied to this email address.
Employer Information

NO HYPHENS! Enter the legal name of the Employer, EXACTLY as you would like to see it in your plan document. Do not type all in upper case or all in lower case; check your spelling and punctuation. No hyphens as they issue a STOP command on form. If using a DBA, or the legal name includes a DBA, please include in the Notes the full legal name and which name you would like us to use as the common name in the documents. Please enter the physical address of the Employer. If you have a P.O. Box or alternate address that you would like the document mailed to, this may be entered in the Notes or on the credit card payment form.

Company Information
Please indicate the form of business.
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. Must be nine digits XX-XXXXXXX, this is not the owner's SSN.
If not Incorporated, what State laws are you governed by?
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Include all W-2 Employees (part-time and full-time), does not need to be exact number. Minimum = 1, No Max
Business Info

NO HYPHENS! Enter the legal name of the Employer, EXACTLY as you Please Provide your Business Information. Form of business, state of incorporation, and FEIN. Must be nine digits XX-XXXXXXX, this is not the owner's SSN.

Legal Name(s) of Affiliated Company(ies)
If another company is owned by this Employer, and they want to include the other company's employees in this benefit, add it as an Affiliate Company. Please print legal name exactly as you would like it to appear in the document. Include FEIN(s) in the Notes.
If you have more than four Affiliated Companies they can be added in the Notes at the end of the order form.
Legal Names of Affiliated Companies

If another company is owned by this Employer, and they want to include the other company's employees in this benefit, add it as an Affiliate Company. Please print legal name exactly as you would like it to appear in the document. Include FEIN in the Notes.

Name of Plan Administrator: (Employer unless otherwise stated)
or
The Plan Administrator is typically the Employer. Unless there is a specific entity that you would like designated as Plan Administrator, you may leave the Plan Administrator fields blank.
Example: (123) 456-7890, If the Plan requires submission of Claims, this Fax # will be included on the Claim Form instead of the Employer's Fax #
Plan Administrator

The Plan Administrator is typically the Employer. Unless there is a specific entity that you would like designated as Plan Administrator, you may leave the Plan Administrator fields blank.If the Plan requires submission of Claims, this Fax # will be included on the Claim Form.

Name of Benefit Programs to be Offered
Add other types of insurance not listed such as Specified Illness, Critical Care, etc.
Select All Insurance Premiums that are applicable

Reimbursement of (non-employer sponsored) Individual Health Insurance can only be reimbursed post-tax, all other employer sponsored group health plan premiums can be pre-taxed. Group Term Life Insurance can be pre-taxed for the Employee only, and limited to the first $50,000 of face value. Other types of insurance may include Specified Illness, Critical Care, and other eligible health and accident policies.

Effective date will be
OR
Choose New Plan or Amended Plan

If you have never provided this benefit before, choose New Plan - A and enter first date of pay period when benefit will begin. If you began giving this benefit to your Employees more than three months ago, chose an Amended Plan - give dates for B and C.

Eligibility requirements
Employee must be regularly scheduled to work __ or more hours per week. Minimum-1, Typical-32, Maximum-40
Who is Eligible

Minimum = 1 Maximum = 40

Plan year - The first plan year will be

If you are starting mid-year, your first Plan Year will be a short Plan Year.

(Example: January 1 to December 31)
OR
(Indicate Start Day and End: Example June 1 to Dec. 31)
Plan Year

In most cases, the Plan Year will be January 1, through December 31. Or the Plan Year can coincide with the Employer Health Plan, however the Employer may choose any twelve month period.

Waiting Period
For Section 125 Plans: Your plan document waiting period just allows employees to pre-tax their insurance premium, it does not make them eligible for your group insurances (1st day of Employment allows them to pre-tax premium as soon as they are eligible for insurance). Health FSA can have longer waiting period than POP or Dependent Care FSA. Min = 1st day of Employment, Max = 3 yrs. Simple Cafeteria Plan = 1,000 hours during the preceding plan year (19 hours per wk) or less.
Employees can participate the first day of the month following this number of days of employment.
If more space is needed, please add your description of eligibility requirements in the Note section at the end of the Order form.
Plan Activation

Please enter the number of days of employment before employee eligibility. Minimum = First day of Employment. Typical = First day of month after 30, 60 or 90 consecutive days of employment.

No fields available for this form.

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Wrap SPD
Please see our Wrap SPD webpage for more information.
What is a Wrap SPD?

If you offer group health insurance you're now by ERISA law, enforced by the Department of Labor and now the Affordable Care Act, to distribute a Wrap SPD within 120 days of the Plan's effective date. Failure to provide the Wrap SPD within 30 days of request triggers a $110 a day fine per participant. Not having a Wrap SPD can also trigger an audit by the Department of Labor. The insurance company's Master Contract, Certificate of Coverage, or Summary of Benefits is not a Wrap SPD. This requirement applies to all employer sponsored group health insurance offerings, including a one-person plan. See our Wrap SPD webpage in the blue drop down menu for more information.

Choose Your Plan Options

$ 179

PDF Document Processed Quickly and Sent Via E-Mail

Basic PDF Option - New Core Section 125 Premium Only Plan Document - PDF email

$ 229

Receive both the printed document and binder AND free PDF email version.

Deluxe Binder - PDF and Printed plan document in 3 ring professional binder shipped via Priority Mail

$ 129

This option only available to existing Core Documents clients.

Additional Plan Document Options

$ 30

Documents provided in PDF format only. Forms in MS Word format

$ 25

Documents provided in PDF format only. Forms in MS Word format

$ 25

Documents provided in PDF format only. Forms in MS Word format

$ 100

Save 33% off normal $149 FSA price when added to the Premium Only Plan. Health FSA employee contribution set at $3,400 by the IRS. To limit the FSA employee contribution indicate preferred annual limit in the Notes area below. Delivered via email in PDF format unless the binder option is chosen above.

$ 100

Save 33% off normal $149 DCAP FSA price when added to the Premium Only Plan. DCAP employee contributions set at $7,500 by the IRS. To limit the DCAP FSA employee contribution please indicate preferred annual limit in the Notes area below. Delivered via email in PDF format unless the binder option is chosen above.

Notes Section

Add any special notes regarding a dba name, delivery address (physical and email), eligibility requirements, etc. For HRA plan documents please give us as much detail as possible about exactly how you would like your custom HRA to be designed. A benefit specialist will contact you regarding specific questions, plan design issues, or additional information needed.

Order Summary
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