Request for Section 105 Insurance and Medical Expense Reimbursement Plan Documents

Request for Section 105 HRA Comprehensive Plan Document

This is to request that Core Documents prepare a Section 105 HRA Comprehensive Plan Document, Summary Plan Description, Administrative Forms, Administrative Handbook, and Resolution to Adopt the Plan. I understand the documents are to be returned to me within approximately two to three weeks. I further understand that the preparation fee includes follow-up contact, initiated by me, to explore any related questions.

	Purchaser Information (i.e. Accountant, Agent, TPA, Payroll Company etc.)
	First Name	*
	Last Name	*
	Company Name	*
	Address	*
	City	*
	State	*
	Zip	*
	Phone	*
	Fax
	Email	*

	Employer Information for Plan Documents
	First Name	* (document signer)
	Last Name	* (document signer)
	Company Name	*
	Address	*
	City	*
	State	*
	Zip	*
	Phone	*
	Fax
	Email	*


	Form of Business *

Employer Federal Id #	*
State of Inc		Number of Employees

	Legal Name(s) of Affiliated Company(ies) that will be covered by the Plan (if any):
	1.
	2.
	3.
	4.


	Name of Plan Administrator: (employer unless otherwise listed)
	Name
	Address
	City
	State
	Zip
	Phone

Effective date will be: *

a) A New plan effective date as of (Date) (mm/dd/yyyy)

b) An amended/restatement of previously established HRA as of (date) (mm/dd/yyyy)

If this is an amended and restatement, state the effective date of the original plan (Date) (mm/dd/yyyy)

Plan year - The first plan year will be:*

A 12 consecutive month period beginning (mm/dd/yyyy) and ending (mm/dd/yyyy)

A short plan year beginning (mm/dd/yyyy) and ending (mm/dd/yyyy)

Eligibility requiements: All employees who will work more than hours per week.

Waiting Period: employees can participate the first day of the month following days of employment.

Deductible Gap Questions:
If this plan is used with a High Deductible Health Plan please answer the following questions:

Single Deductible*

Employee will pay the first $ HRA Plan will pay the next $

Not Applicable

Family Deductible*

Employee will pay the first $ HRA Plan will pay the next $

Not Applicable

Dollar Limit on Expenses: *

Please designate the annual limit on expenses to be reimbursed: $

Funds Availability: *

Will this full amount be available in a lump sum or will the benefit accumulate monthly? Monthly Lump Sum

Protected Health Information Designee: *

(PHI Person) Please name the person who will be responsible for the proper handling of medical information protected under HIPAA law:

Carryover of Unused Funds: *

Will unused funds carryover to the next Plan Year? Yes No

How did you hear about Core Documents? *

or, Other:

Choose Your Plan Options: *

Section 105 Insurance, and Medical Reimbursement Plan Document

$ 99.00 (Plus $15 Shipping & Handling)

Annual Document Maintenance Plan

$ 69.00 (billed every 12 months)

Rush Order (Please Attach your Fed Ex #)

$ 29.00

Summary Plan Description & Election Forms on a Disk

$ 29.00

Please include a paragraph or two about how you would like to design your HRA Plan regarding Annual Maximum Benefits, Individual limits, Family limits if any, whether the annual amount will rollover from one year to the next year, etc.

Notes :

PLEASE VERIFY YOU HAVE COMPLETED ALL OF THE APPROPRIATE

SECTIONS ABOVE BEFORE CONTINUING

Address

	From the order review page (next page) there are three options to finalize your order:
	1. Proceed to the secure on-line charge card payment form.
	2. Print the order review page, (next page) complete the credit card section manually and fax to (941)795-4802.
	3. Print the order review page (next page) and fax it with a copy of your check to Core Documents (941)795-4802.

	If paying by check, make payable to Core Documents.
	Core Documents, Inc.
	P.O. Box 14538
	Bradenton, FL 34280-4538		Copyright(c) 2005 Core Documents, Inc.
	Voice: 941-755-3373 or 888-755-3373		All Rights Reserved
	Fax: 941-795-4802
	Email: Service@CoreDocuments.com