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.).
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.
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.
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.
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.
New IRS regulations allow one of these two options for spending unused Health FSA benefits. The $500 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.
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.
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.
Minimum = 1
Maximum = 40
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.
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