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.).

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.
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.

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.
Name of Benefit Programs to be Offered:

Select All Insurance Premiums that are applicable

Reimbursement of (non-employer sponsored) Individual Health Insurance can only be reimbursed post-tax, all other employer sponsored group health plan premiums can be pre-taxed. Group Term Life Insurance can be pre-taxed for the Employee only, and limited to the first $50,000 of face value. Other types of insurance may include Specified Illness, Critical Care, and other eligible health and accident policies.

                                         Group Health Insurance
                                         Dental Insurance
                                         Vision Insurance
                                         Group Term Life
                                         Short Term Disability
                                         Long Term Disability
                                         Cancer Insurance
                                         Accidental Death & Dismemberment
                                         Intensive Care Insurance
                                         Accident Insurance
                                         Hospital Indemnity Insurance
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

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.

Wrap SPD

    Do you have the Department of Labor and the Affordable Care Act required Wrap SPD for your Group Insurance Plan?

What is a Wrap SPD?

If you offer group health insurance youíre now required by ERISA law, enforced by the Department of Labor and now the Affordable Care Act, to distribute a Wrap SPD within 120 days of the Planís effective date. Failure to provide the Wrap SPD within 30 days of request triggers a $110 a day fine per participant. Not having a Wrap SPD can also trigger an audit by the Department of Labor. The insurance companyís Master Contract, Certificate of Coverage, or Summary of Benefits is not a Wrap SPD. This requirement applies to all employer sponsored group health insurance offerings, including a one-person plan. See our Wrap SPD webpage in the blue drop down menu for more information.

We value your feedback

    How did you hear about us?

Customer Survey

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

Choose Your Plan Options

Deluxe Binder - PDF and Printed plan document in 3 ring professional binder shipped via Priority Mail 149.00
Receive both the printed document and binder AND free PDF email version.

Basic PDF Option - New Core Section 125 Premium Only Plan Document - PDF email 99.00
PDF Document Processed Quickly and Sent Via E-Mail

Update PDF option - Update an Existing Core Section 125 Plan Document - PDF email 89.00
This option only available to existing Core Documents clients.

HSA Module - pretax HSA savings for additional 7.65% tax savings 30.00

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 25% when added to new document order 79.00
This option entitles you to one plan document amendment in the first 24 months. Save 11% off the normal $89.00 update price.

Health Flexible Spending Account (FSA) Pretax medical expenses 100.00
Save 22% off normal $129 FSA price when added to the Premium Only Plan. Health FSA employee contribution set at $2850 by the IRS. To limit the FSA employee contribution indicate preferred annual limit in the Notes area below. Delivered via email in PDF format unless the binder option is chosen above.

Dependent Care Assistance Plan (FSA) Pretax childcare -Save 22% 100.00
Save 22% off normal $129 DCAP FSA price when added to the Premium Only Plan. DCAP employee contributions set at $5000 by the IRS. To limit the DCAP FSA employee contribution please indicate preferred annual limit in the Notes area below. Delivered via email in PDF format unless the binder option is chosen above.
Notes Section

    Please utilize the notes section below.

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.


Powered By Empire Computers