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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


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.

                                             
*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.
Dependent Care FSA Annual Limit

    The IRS allows up to $5,000 annually. Do you want to limit that amount?


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Health FSA Annual Plan Limit:

    The IRS limits Health FSA plans to $3,200 in employee contributions (effective 01/01/2024). Choose the standard $3,200 option, or designate a lower employee contribution limit in the option below.


Annual Plan Limit


New IRS regulations allow one of these two options for spending unused Health FSA benefits. The $640 Carryover Provision limits the amount carried over without time restrictions. The 2.5 month Grace Period provision has no limit on funds but only 2.5 months to spend down unused plan benefits.




                                 $640 Carryover Provision
Employees can carryover up to $640 of unused Health FSA benefits to the next plan year.

                                 2.5 month Grace Period Provision
Employee has 2.5 months after plan year to spend-down unused Health FSA benefits
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.

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 (125 Med & 129 FSA)


               
Deluxe Binder - New Health FSA & Dependent Care Assistance Plan Document PDF and Printed plan document in 3 ring professional binder shipped via Priority Mail 249.00
Receive both the printed document and binder AND free PDF email version.

               
Basic PDF Option - Health FSA & Dependent Care Assistance Plan Documentt - PDF email 199.00
PDF Document Processed Quickly and Sent Via E-Mail

               
Update PDF option - Update an Existing Health FSA & Dependent Care Assistance Plan Document - PDF email 169.00
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.

               
Section 125 Premium Only Plan Document - pretax insurance premium 99.00
Delivered via email in PDF format unless the binder option is chosen above.
Notes Section

    Please utilize the notes section below.



Next Step

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