$99 Section 125 Premium Only Plan Document Order Form

	Request for Section 125 Premium Only Plan Document

This is to request that Core Documents prepare a Section 125 Premium Only Plan Document and Summary Plan Description, Administrative Forms, Administrative Handbook,and Resolution to Adopt the Plan to be returned to me within approximately two 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	*

	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

Name of Benefit Programs to be Offered: (Check those you wish to include)
	Health Insurance Dental Insurance Vision Insurance Group Term Life Accident Insurance Cancer Insurance Other


	Effective date will be: *
	a) A New plan effective date as of (Date) (mm/dd/yyyy)
	b) An amended/restatement of previously established Section 125 Plan 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) ending (mm/dd/yyyy)
	A short plan year beginning (mm/dd/yyyy) 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.

	How did you hear about Core Documents? *
	or, Other:
	Choose Your Plan Options:*
	Section 125 Premium Only Plan Document	$ 99.00 (Plus $15 Shipping and 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

	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