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.
If this form doesn't allow you to choose or omit the COVID-19 relief options please include detailed notes below. Simply tell us exactly how you would like your plan document customized for your group.Options through 2021 include -Provides flexibility with respect to carryovers of unused amounts from the 2020 and 2021 plan years;Extends the permissible period for incurring claims for plan years ending in 2020 and 2021;
Provides a special rule regarding post-termination reimbursements from health FSAs during plan years 2020 and 2021; Provides a special claims period and carryover rule for dependent care assistance programs when a dependent “ages out” during the COVID-19 public health emergency; andAllows certain mid-year election changes for insurance premium, health FSAs and dependent care assistance programs for plan years ending in 2021.