ERISA Wrap SPD Plan Document just $149 one-time fee

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.

Choose Your Plan Options

Deluxe Binder - New Core Group Insurance Wrap SPD Plan Document

$ 199.0

Email PDF version processed ASAP AND Printed 3-ring binder with tabbed index shipped via Priority Mail

Deluxe Binder - New Core Group Insurance Wrap SPD Plan Document

Basic PDF Option - New Core Group Insurance Wrap SPD

$ 149

PDF Document Processed Quickly and Sent Via E-Mail

Basic PDF Option - New Core Group Insurance Wrap SPD

Additional Plan Document Options

Plan Document USB stick Mailed - in addition to PDF email and/or mailed binder

$ 25

Documents provided in PDF format only. Forms in MS Word format. Always have a safe backup copy of your plan document on USB.

Rush Order - automatically queued up for priority processing

$ 25

Supplemental Insurance SPD Module

$ 30

Include all supplemental benefit insurance plans such as dental. vision. critical illness. or hospital indemnity.

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

Updates as you change your selections

Plan option —: $0.00
Additional options: $0.00
Subtotal: $0.00
Discount 0%: -$0.00

Coupon code

Total due today $0.00

Next Step

You can Review your Selection on the Next Page. Use the Back button to return here for corrections. All fields should retain filled content (if you have Cookies activated) except for a couple check boxes. Please check all fields before continuing if returning for corrections.

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:

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:

Name of Insurance Carrier(s)
Health Insurance Carrier #1
Health Insurance Carrier #2
Health Insurance Carrier #3
Ancillary
FTE Method
PCP Designation
Grandfathered
Funding Mechanism
Employer General Assets
Employee Contributions
Trust Account
Union or Collective Bargained Agreement
Other Employee Organization
Assigned Plan Number
Plan Identification for Reporting Purposes
Other plan number
Documenting Method for Identifying Full-Time Employees
Documenting Method
Statement of Grandfathered Status
Grandfather
Notice of Patient Protections and Selection of Providers
Designation Required
Supplemental Insurance SPD Module
Dental Insurance
Vision Insurance
Group Term Life
Accidental Death & Dismemberment
Short Term Disability
Long Term Disability
Accident Insurance
Critical Illness Insurance
Cancer Insurance
Intensive Care Insurance
Other insurance 1
Other insurance 2
Other insurance 3
Other insurance 4

ERISA Wrap SPD Plan Document just $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

Name of Insurance Carrier(s)

Funding Mechanism

Assigned Plan Number

Documenting Method for Identifying Full-Time Employees

Statement of Grandfathered Status

Notice of Patient Protections and Selection of Providers

Supplemental Insurance SPD Module

We value your feedback

Choose Your Plan Options

Additional Plan Document Options

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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