Purchaser Information

First Name

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.

Last Name

Company Name

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.

Address

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.

City

City where we ship the plan document, if binder option is chosen.

State

Zipcode

12345-

Phone

Example: (123)456-7890

Ext

Example: 1234

Fax

Example: (123) 456-7890

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

First Name

Normally the business owner or Key Employee. Please enter the first name of the person authorized to sign the plan document.

Last Name

Normally the business owner or Key Employee. Please enter the last name of the person authorized to sign the plan document.

Company Name

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.

Address

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.

City

State

Zipcode

12345-

Phone

Example: (123) 456-7890

Fax

Example: (123) 456-7890

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.

Legal Name(s) of Affiliated Company(ies)

Please be sure to include the FEIN Number in the notes section below.

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

Name of Plan Administrator: (Employer unless otherwise stated)

Name

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.

Address

City

State

Zipcode

Phone/ Fax

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.

Effective date will be

New Plan (add Effective Date below)

Effective Date of New Plan

Month

Day

Year

Amended Plan (Effective & Original Dates below)

Amended Plan

Month

Day

Year

Original Plan

Month

Day

Year

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

All employees regularly scheduled to work ____ or more hours per week.

Hours per Week :

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.

First Plan Year is 12 consecutive months (Example: January 1 to December 31)

Start Date

Month

Day

End Date

Month

Day

First Plan Year is a Short Plan Year (Indicate Start Day and End: Example June 1 to Dec. 31)

Start Date

Month

Day

End Date

Month

Day

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

Employees are eligible the first day of the month coinciding with or next following ____ consecutive days of employment.

Special Scenario

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.

Number of Days

Employees can participate the first day of the month following this number of days of employment.

Other

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.

Health FSA Annual Plan Limit:

The IRS limits Health FSA plans to $3,400 in employee contributions (effective 01/01/2026). Choose the standard $3,400 option, or designate a lower employee contribution limit in the option below.

Annual Plan Limit

Please Choose One:

$680 Carryover Provision

2.5 Month Grace Period Provision

Choose Your Plan Options

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

$ 199

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

Basic PDF Option - New Core Health FSA Plan Document - PDF email

$ 149

PDF Document Processed Quickly and Sent Via E-Mail

Basic PDF Option - New Core Health FSA Plan Document - PDF email

Update PDF option - Update an Existing Core Health FSA Plan Document - PDF email

$ 129.00

This option only available to existing Core Documents clients.

First Name:		Last Name:
Company Name:		Address:
City:		State:
Zipcode:		Phone: Ext:
Email:		FAX:
E-Mail/Ship to:

Employer First Name:		Employer Last Name:
Employer Company Name:		Employer Address:
Employer City:		Employer State:
Employer Zipcode:		Employer Phone:
Employer Email:		Employer FAX:

Type of Company:		Employer Federal ID#:
State of Incorporation:		Number of Employees:

1:		2:
3:		4:

Name:		Address:
City:		State:
Zip:		Phone:

Health FSA (Flexible Spending Arrangement) Plan Documents – $149 one-time fee

Purchaser Information

Employer Information for Plan Documents

Company Information

Legal Name(s) of Affiliated Company(ies)

Name of Plan Administrator: (Employer unless otherwise stated)

Effective date will be

Eligibility requirements

Plan year - The first plan year will be

Waiting Period

Health FSA Annual Plan Limit:

Choose Your Plan Options

Additional Plan Document Options

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Notes Section

Order Summary

Next Step

Please Review Your Order

Purchaser Information

Employer Information

Company Information

Legal Name(s) of Affiliated Company(ies)

Administrator Information

Plan Information

Selected Plan Option(s)

Additional Information

Notes

Pricing Summary

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Effective Date is:		Plan year - The first plan year will be:
Waiting Period:
Eligibility Requirements:		How did you hear about Core Documents?

Plan Option:
Additional Plan Document Options:
Selected Benefits:

Health FSA Annual Plan Limit:
Annual Plan Limit
Please Choose One: