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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.
COVID 19 Plan Amendment

    

COVID-19 Plan Amendment Effective Date will be:


COVID-19 Tips


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; and

Allows certain mid-year election changes for insurance premium, health FSAs and dependent care assistance programs for plan years ending in 2021.

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COVID 19 Mid-Year Election Change Limit



                                 1 Per Year
                                 Other (Put in Notes)

Allow mid-year election change for Group Health Insurance Coverage?



                                 YES
                                 NO

Allow mid-year election change for Group Supplemental Insurance coverage?



                                 YES
                                 NO

Allow mid-year election changes for FSAs?



                                 YES
                                 NO

Provide Extended Claims Period option for FSA expenses up to 12 months: (Check all that Apply or detail your specific FSA extended claim design criteria in the Notes Area below)



                                 Health FSA
                                 DCAP FSA
                                 Limited Purpose Health FSA

Please Choose a Carryover Option for 2022



                                 $570 unused funds
                                 2.5 extra months
                                  100% Carryover

Allow eligible over-the-counter (OTC) medical products, feminine products retroactive to 1-1-2020 (Cares Act).



                                 YES
                                 NO



Choose Your Plan Options (COVID-19)


               
E-Mail PDF Option - COVID-19 Plan Document - PDF email 99.00
PDF Document Processed Quickly and Sent Via E-Mail

               
Deluxe Binder - COVID-19 Plan Document PDF and Printed plan document in 3 ring professional binder shipped via Priority Mail 149.00
Receive both the printed document and binder AND free PDF email version.
Notes Section

    Please utilize the notes section below.



Next Step

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