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Purchaser Information

    Click an input box for help information.


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.).

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Employer Information for Plan Documents

Employer Information


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. 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.

                                             
*Auto-Fills Purchaser Information in the Employer Fields Below.
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Company Information

Business Info


Please Provide your Business Information. Form of business, state of incorporation, and FEIN Required. Must be nine digits XX-XXXXXXX, this is not the owner's SSN.

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Legal Name(s) of Affiliated Company(ies)

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


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)

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.

                                             
*Auto-Fills Purchaser Information in the Plan Admin Fields Below.
                                             
*Auto-Fills Employer Information in the Plan Admin Fields Below.
Effective date will be:

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.




                  New Plan (add Effective Date below)



                  Amended Plan (Effective & Original Dates below)
Plan year - The first plan year will be

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


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.




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



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

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


Who is Eligible


Minimum = 1 Maximum = 40

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Waiting Period:

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


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.

Deductible Gap Questions:

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


Dollar Limit on Expenses:

    Please designate the annual limit on expenses to be reimbursed:


Limit Expenses


Here you can designate an annual limit on reimbursed expenses.

Funds Availability:

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



If entire HRA benefit is available on the first day of the Plan Year, choose Lump Sum/Annual. Most Deductible Gap Plans are Annual. It is typical for the Comprehensive HRA benefit to be contributed on the first of each month.


                                 Monthly
                                 Lump Sum/Annual

Protected Health Information Designee

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


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Notes Section

    Please utilize the notes section below.



We value your feedback

    How did you hear about us?


Customer Survey


Please take a moment to provide some feedback on your experience.

Carryover of Unused Funds:

    Will unused funds carryover to the next Plan Year?


Choose Your Plan Options (105 HRA)


               
Deluxe Binder - New One Person Section 105 HRA Plan Document PDF and Printed plan document in 3 ring professional binder shipped via Priority Mail $199.00
Receive both the printed document and binder AND free PDF email version.

               
Basic PDF Option - One Person Section 105 HRA Plan Document - PDF email $149.00
PDF Document Processed Quickly and Sent Via E-Mail

               
Update PDF option - Update an Existing One Person Section 105 HRA Plan Document - PDF email $129.00
This option only available to existing Core Documents clients.


               
Plan Document. SPD. Administrative Sections & Forms on CD mailed $25.00
Documents provided in PDF format only. Forms in MS Word format

               
Rush Order - automatically queued up for priority processing $25.00

               
2nd Year Update - discounted 23% when added to new document order $99.00
This option entitles you to one plan document amendment in the first 24 months. Save 23% off the normal $129.00 update price.

               
CoreData Excel Spreadsheet Software Administer FSA plans yourself $20.00
Excel Spreadsheet Software
Next Step

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