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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.

We value your feedback

    How did you hear about us?


Customer Survey


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

Name of Insurance Carrier(s)

Insurance Carriers


Example: Blue Cross Blue Shield, United Healthcare, etc.

Funding Mechanism



                                                Employer General Assets
                                                Employee Contributions
                                                Trust Account
                                                Union or Collective Bargained Agreement
                                                Other Employee Organization
Assigned Plan Number

    Plan Identification for Reporting Purposes.


Documenting Method for Identifying Full-Time Employees

    The Core Wrap SPD defaults to the standard Monthly Measurement Period where every employee working 31 or more hours last month are full-time. The Look Back Period alternative method is for groups with employees who work a flexible schedule (or as needed) and there is no way to actually determine if they will be full-time (for purposes of the ACA fines) or part time (30 hours or less). The Look Back Method allows for a Safe Harbor period of time, determined by the employer, of not less than 3


IRS Notice 2012-58


Effective in 2014, the health care reform law imposes penalties on employers with at least 50 full-time equivalent employees if they do not offer health coverage to their employees or if they offer health coverage to their employees that is not “affordable” or does not provide “minimum value” and certain other requirements are met.




                                                Monthly Measurement Period
                                                Look Back Alternative
Statement of Grandfathered Status

    Please choose Yes below if your plan is grandfathered.





                                                Yes
                                                No
Notice of Patient Protections and Selection of Providers

    Does your health insurance require the designation of a Primary Care Provider?


Primary Care Provider


If a group health plan or health insurance issuer requires the designation by a participant or beneficiary of a primary care provider, the plan or issuer must provide a notice informing each participant of the terms of the plan or health insurance coverage regarding designation of a primary care provider.




                                                Yes
                                                No
Choose Your Plan Options (SPD Module)


               
Deluxe Binder - New Core Group Insurance Wrap SPD Plan Document 149.00
Email PDF version processed ASAP AND Printed 3-ring binder with tabbed index shipped via Priority Mail

               
Basic PDF Option - New Core Group Insurance Wrap SPD 99.00
PDF Document Processed Quickly and Sent Via E-Mail


               
Plan Document CD Mailed - in addition to PDF email and/or mailed binder 25.00
Documents provided in PDF format only. Forms in MS Word format. Always have a safe backup copy of your plan document on CD.

               
Rush Order - automatically queued up for priority processing 25.00

               
Supplemental Insurance SPD Module 30.00
Include all supplemental benefit insurance plans such as dental. vision. critical illness. or hospital indemnity.
Supplemental Insurance SPD Module

    Please include all Supplemental Insurance Carriers by plan.


Supplemental Insurance


Adding Supplemental Insurance Carriers will activate the $30 Supplemental Insurance Module Option.

Notes Section

    Please utilize the notes section below.



Next Step

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