Section 127 EAP Educational Assistance Program

Purchaser Information

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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.).

First Name *

Last Name *

Company Name *

Address *

City *

State

Zip Code *

Phone *

Fax

E-Mail *

Choose Below

E-Mail/Ship to Purchaser
E-Mail/Ship to Employer

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.

First Name *

Last Name *

Company Name *

Address *

City *

State

Zip Code *

Phone *

Fax

E-Mail *

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.

Form of Business

Employer Federal ID# *

State of Incorporation

Number of Employees *

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

Address

City

State

Zip Code

Phone / Fax

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 Document

New Plan (add Effective Date below)

A) Effective Date of New Plan

-OR-

Amended Plan (Effective & Original Dates below)

B) Effective Date of Amended Plan

C) Effective Date of Original Plan

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.

Select Plan Year Type

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

Plan Year Start Date

Plan Year End Date

-OR-

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

Start Date

End Date

Eligibility requirements:

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

Who is Eligible

Minimum = 1 Maximum = 40

Hours per Week: *

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.

Special Scenario

Number of Days

Other

Section 127 EAP - Educational Assistance Program

Please choose to pay for either Tuition, Loan Relief or both.

Section 127 EAP Educational Assistance Program

Please choose what your EAP will pay for.

Your EAP will pay for:

                                 Ongoing Education Tuition Assistance Only
                                 Student Loan Relief Only
                                 Education Tuition Assistance and Student Loan Relief

Section 127 EAP - Plan Limit

$5,250 annually is allowed for EAPs; will you offer?

Plan Limit Amount

Choose either the standard $5,250 or enter a custom limit in the box provided.

Your plan will offer:

$5,250 annually
Custom Limit

Custom Limit

Section 127 EAP - Course Requirements

Please specify which courses qualify under the EAP plan.

Section 127 EAP - Course Requirements

Choose either related business course only, or any form of instruction or training that improves or develops the capabilities of an individual.

Choose From

Business related courses only
Any form of instruction or training that improves or develops the capabilities of an individual

Section 127 EAP - Minimum Required Grade

Will Employee be required to completes the course with a particular grade level or higher?

Section 127 EAP - Minimum Required Grade

Will Employee be required to completes the course with a particular grade level or higher?

Grade Required

No
Yes (Explain)

Please Explain

Section 127 EAP - Recovery of Benefits

Will participating employees be required to pay back EAP benefits if they leave employment prior to a designated period of time?

EAP Repayment Agreement

Will participating employees be required to pay back EAP benefits if they leave employment prior to a designated period of time?

Pay Back Benefits

                                 Yes
                                 No
                                 Employees who leave employment within __________                                      months (i.e. 6/12/24 months etc.) of the last annual claim                                      will be required to pay back last annual EAP benefit to                                      employer.

Time Period

We value your feedback

How did you hear about us?

Customer Survey

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

Method:

Other:

Notes Section

Please utilize the notes section below.

NOTES AREA: Add any special notes regarding a dba name, delivery address (physical and email), eligibility requirements, etc. For HRA plan documents please give us as much detail as possible about exactly how you would like your custom HRA to be designed. A benefit specialist will contact you regarding specific questions, plan design issues, or additional information needed.

Choose Your Plan Options (127 EAP)

Choose one of these three plan document options:

Deluxe Binder - 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 - New Core Section 127 Education Assistance Plan Document - PDF email 149.00

PDF Document Processed Quickly and Sent Via E-Mail

Update PDF option - Update an Existing Core Section 127 Education Assistance Plan Document - PDF email 129.00

This option only available to existing Core Documents clients.

Additional Plan Document Options:

Plan Document. SPD. Administrative Sections & Forms on USB stick mailed 25.00

Documents provided in PDF format only. Forms in MS Word format

Rush Order - automatically queued up for priority processing 25.00

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.

Click an input box for help information.

Purchaser Name

We normally ship the document to the Purchaser if the binder option is chosen. If this is NOT the address that you would like the plan document shipped to, please indicate the correct shipping address on the credit card payment form and/or in the Notes section at the bottom of this order form.

City where we ship the plan document, if binder option is chosen.

Example: (123)456-7890

Example: (123) 456-7890

We normally email the PDF copy of the plan document to the Purchaser's email. If this is not the email for delivering the plan document please indicate the correct delivery email in the Notes area at the end of this order form.

Employer Information

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

Normally the business owner or Key Employee. Please enter the first name of the person authorized to sign the plan document.

Normally the business owner or Key Employee. Please enter the last name of the person authorized to sign the plan document.

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.

#####-####

Example: (123) 456-7890

Example: (123) 456-7890

Indicate in the Notes area below if you would like to have the plan document PDF copied to this email address.

Business Info

Please indicate the form of business.

Required. Must be nine digits XX-XXXXXXX, this is not the owner's SSN.

If not Incorporated, what State laws are you governed by?

Include all W-2 Employees (part-time and full-time), does not need to be exact number. Minimum = 1, No Max

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(s) in the Notes.

If you have more than four Affiliated Companies they can be added in the Notes at the end of the order form.

Plan Administrator

*Auto-Fills Purchaser Information in the Plan Admin Fields Below.

*Auto-Fills Employer Information in the Plan Admin Fields Below.

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.

Example: (123) 456-7890, If the Plan requires submission of Claims, this Fax # will be included on the Claim Form instead of the Employer's Fax #

Choose New Plan or Amended Plan

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

Plan Year

(Example: January 1 to December 31)

Choose Date on Calendar

Choose Date on Calendar

(Indicate Start Day and End: Example June 1 to Dec. 31)

Choose Date on Calendar.

Choose date on the calendar.

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

Who is Eligible

Employee must be regularly scheduled to work __ or more hours per week. Minimum-1, Typical-32, Maximum-40

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

Plan Activation

Employees can participate the first day of the month following this number of days of employment.

If more space is needed, please add your description of eligibility requirements in the Note section at the end of the Order form.

Please choose to pay for either Tuition, Loan Relief or both.

Section 127 EAP Educational Assistance Program

$5,250 annually is allowed for EAPs; will you offer?

Plan Limit Amount

Please specify which courses qualify under the EAP plan.

Section 127 EAP - Course Requirements

Will Employee be required to completes the course with a particular grade level or higher?

Section 127 EAP - Minimum Required Grade

Will participating employees be required to pay back EAP benefits if they leave employment prior to a designated period of time?

EAP Repayment Agreement

Leave Employment before X Months

How did you hear about us?

Customer Survey

How did you hear about us?

Please utilize the notes section below.

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.