Plan Document Information Form
 
This form may be used to request an order for a Resolution establishing the following selected Plan Document(s)
and Summary Plan Description, Administrative Forms, and Resolution to Adopt the Plan(s) to be returned to me within approximately 1 week. I further understand that the preparation fee includes follow-up contact, initiated by me, to explore
any related questions.
 


Select each component plan that you wish to include in your overall Cafeteria Plan.

Section 105 Health Reimbursement Arrangement Plan (HRA)
Section 125 Individual Premium Only Reimbursement Plan
Section 125 Health Flexible Spending Account Plan
Section 129 Dependent Care Flexible Spending Account Plan                                            * Indicates Required Information
Employer Information:    
* First Name:   (document signer)  
* Last Name:  (document signer)  
* Company Name:    
* Mailing Address:    
     
* City:    
* State:    
* Zip Code:    
* Phone Number:    
 
  
Fax Number:
   
* E-mail Address:    

Business Information:    
 
*
Form of Business:
 
C Corporation
S Corporation
Partnership
Sole Proprietor
 
 
LLC (Limited Liability Company)
LLP (Limited Liability Partnership)
Non-Profit 501(c)(3)
* Employer Federal ID #: * State of Incorporation:
* Fiscal Year End Date: * Number of Employees:
 
 
 Legal Name(s) of any Affiliated Company(ies) that will be covered by the Plan (if any):
 
       1.    
       2.    
       3.    
       4.  
 
 
   Name of Plan Administrator (Employer unless otherwise listed):  
       Name:           
       Address:      
       City:            
       State:          
       Zip:             
       Phone:         

Basic Plan Information:
 
   
* List the Plan Number and name of all previous or existing Benefit Plans (usually 501 or greater)
 
                
 
* Effective date will be:

    (When choosing your effective
    date, be sure to allow for time
    to receive and sign your
    documents, as well as any
    necessary election period)
A) A NEW plan effective date as of (Date)  (MM/DD/YYYY)
B) An AMENDED/RESTATEMENT of previously established Section 125 Plan
         as of (Date) 
(MM/DD/YYYY)
     
     If B): state the effective date of the original plan (Date)  (MM/DD/YYYY)
                  state the previous Plan Number 
 
*
Plan Year - The first plan
   year will be a:
 
 
12 consecutive month period - starting  and ending 
Short plan year -                    starting  and ending 
 
*
Eligibility Requirements:
 
All employees who will work more than 
hours per week
 
*
Waiting Period:
Employees can participate the 1st day of the month following  days of employment
(See Defaults Section for exception for POP plans)
 
 
*
COBRA:
 
As an employer are you/will your Health Care Reimbursement Account be subject to COBRA?
(Generally COBRA applies to employers who employed 20+ employees in the prior calendar year.)
 
Yes         No
     If "Yes", please specify a COBRA Notice Contact Person:
 
 
*
HIPAA:
 
As an employer are you or will your Health Care Reimbursement Account Plan be subject to
HIPAA privacy rules?

(Self-funded health plans with <50 participants that are administered by the employer are normally exempt.)
Yes         No
 
 
*
FMLA:
 
As an employer are you or would your plan be subject to the Family Medical Leave Act/FMLA?
(Normally applies to employers with 50+ employees.)
Yes         No
 
Default Plan Settings:
 
 
    The following default settings are utilized. To use the default listed, no action is necessary.
 
    If you wish to use a setting other than the default setting, check the box to the left of the item to indicate a customized
    setting is needed. Check ONLY settings you wish to change. Then indicate the customized setting in the location provided.
 
    Year End Runout: Default:  The number of days after the end of the Plan Year by which claims for
             reimbursement must be filed with the Plan Administrator is set to 30 days.
 
    Customize This Setting: 60 Days    90 Days    Other: 
 
    Termination Runout: Default:  The number of days after employee termination by which claims for reimbursement
             must be filed with the Plan Administrator is set to 30 days.
 
    Customize This Setting: 30 Days    60 Days    Other: 
 
    Minimum Age: Default:  Minimum age requirement for an Eligible Employee to become eligible to be a
             Participant in the Plan is 18 years old.
 
    Customize This Setting: 19  20  20.5  21
 
    Rehired Terminated
    Employees:
 
Default:  Terminated Participants who are rehired within 30 days of Termination will
             automatically have benefit elections reinstated and Terminated Participants who are
             rehired more than 30 days after Termination will be permitted new benefit elections.
 
    Customize This Setting: Disallow automatic reinstatement (for <30 days rehires)
                                                                    and/or
                                     
      Disallow new benefit elections (for >30 days rehires)
 
    COBRA Notice Contact
    Person:
Default:  Only applies to plans that designate above that they are subject to COBRA. The
             contact info. for the COBRA Notice Contact Person shall be the same as the Plan
             Sponsor's contact info. specified in the Employer Information section of this form.
 
    Customize This Setting: The COBRA Notice Contact Person shall be an
                                                 Other entity or contact.
 
                                              Name:             
   
                                              Address:         
   
                                              City, State, Zip:   
                                              Phone:                

If you intend to include a Health Reimbursement Arrangement (HRA) component in your Cafeteria Plan, please complete the following section:
HRA Eligible Expenses
Coverage under the Plan for Covered Persons is available for the following Eligible Expenses:
If "Listed medical expenses" is selected above, list the eligible expenses:
Health Reimbursement Account - Maximum Benefit
Enter the maximum annual amount that will be credited to a Participant's Health Reimbursement Account in any Plan Year for one Covered Person (include dollar signs if applicable):
Enter the maximum annual amount that will be credited to a Participant's Health Reimbursement Account in any Plan Year for two Covered Persons:
Enter the maximum annual amount that will be credited to a Participant's Health Reimbursement Account in any Plan Year for more than two Covered Persons:
Health Reimbursement Account Funding Procedures
The amounts shall be credited to the Participant's Health Reimbursement Account at the following times:
   If the above selection is not "Claims dependent" and
   a Participant enters the Plan at a time other than the
   beginning of a the period, the amounts credited to the
   HCRA shall be reduced to reflect the time of actual
   participation in the Plan:
   If the above selection is not "Claims dependent" and a
   change to the number of covered persons affects the
   amount credited to the HRA, the HRA account will be
   prorated to accommodate the change:
   The Plan allows a carryover of the balance in a
   Participant's Health Reimbursement Account to the
   next Plan Year:
   If carryovers are allowed "with limitations", enter the
   maximum dollar amount (or multiple of the maximum
   annual amount) that may be carried over to the next
   Plan Year:
Coordination with Other Plans
Describe method to coordinate coverage in the Plan with a Health Care Reimbursement Account ("HCRA") in a Company-sponsored cafeteria plan for expenses that are reimbursable under both this Plan and the cafeteria plan:
Describe method to coordinate coverage in the Plan with Health Savings Accounts
   If any HRA/HSA coordination option other than "None" is
   chosen, then those limitations shall apply to:
Claims Handling
Specify whether the deadline for filing claims is a specified number of days or by a specified date:
Enter the number of days after the end of the Plan Year or the specified date:
Specify whether the Plan provides for an earlier deadline for claims submission for Terminated Participants:
Specify whether the deadline for filing claims is a specified number of days or by a specified date:
Enter the number of days after Termination or the specified date:
Indicate whether the Company will provide debit, credit, and/or other stored-value cards:

If you intend to include a Premium Conversion (POP) component for Group-sponsored Insurance Plans and/or an Individually-owned Insurance Premium Reimbursement Account (PRA) component in the Cafeteria Plan, please complete the following:
 
    Name of Benefit Programs to be Offered:  (Check those you wish to include)
 
     Employer Sponsored   individually OWNED           plan type                                         
 
 
 
 
 
 
 
 






 
Health Insurance
 
Dental Insurance
 
Vision Care
 
Group Term Life ($50,000 max)
 
Accident Insurance
 
Cancer Insurance
 
Other: 
  POP Default Settings:  
    The following default settings are utilized. To use the default listed, no action is necessary.
 
    If you wish to use a setting other than the default setting, check the box to the left of the item to indicate a customized
    setting is needed. Check ONLY settings you wish to change. Then indicate the customized setting in the location provided.
 
    POP Waiting Period: Default:  Employees are eligible to participate in the POP at the same date as he or she
             becomes eligible to participate in the Insurance Contract(s).
 
    Customize This Setting:  Disallow and only allow POP participation after standard
                                                   Waiting Period
 
    POP Enrollment: Default:  Eligible employees will be automatically enrolled in the POP plan for all covered
             employer sponsored insurance offering they have enrolled in and will have their
             enrollment automatically renewed each year.
 
    Customize This Setting:  Disallow and only allow POP enrollment for employees
                                                   who submit an enrollment form to the Plan Administrator
                                                   each enrollment period
 
    POP Adjustment for
    Insurance Cost
    Changes:
Default:  Pursuant to the terms of Treas. Reg. 1.125-4 changes in the cost of insurance will
             allow automatic adjustment of participant withholdings.
 
    Customize This Setting:  Disallow automatic withholding adjustments for changes
                                                   in cost of insurance

If you intend to include a Medical Expense Reimbursement Flexible Spending Account (FSA) component in your Cafeteria Plan, Please complete the following:
   * Medical FSA Annual Plan Limit:  
     Currently, the only limit on the contribution by an employee to a Medical Expense Reimbursement Account in any Plan Year
     is annual income. However, beginning in the year 2013 as a result of the Health Care Reform Bill (PPACA) the maximum
     limit on Medical Expense Reimbursement contributions under a Section 125 (i) will be limited to $2,500.00.

     As an employer, you have the option to choose a contribution limit that is lower than the IRS mandated limit. You may also
     choose a contribution limit that is greater than the IRS mandated limit. However, beginning in January 1, 2013 the limit will
     be capped and your Plan Document will need to be amended to reflect the change.

     Please note: The employer maintains full responsibility to fund the full annual election chosen by the employee on the first
     day of the plan year should the employee submit eligible claims for reimbursement.
 
     Choose an annual plan limit:  Maximum permitted under Code Section 125(i)   Other:  $    
    MEDICAL REIMBERSMENT FSA ACCOUNT DEFAULT SETTINGS:
    The following default settings are utilized. To use the default listed, no action is necessary.
 
    If you wish to use a setting other than the default setting, check the box to the left of the item to indicate a customized
    setting is needed. Check ONLY settings you wish to change. Then indicate the customized setting in the location provided.
 
    2 Month Grace
    Period:
Default:  Allowed for the Health FSA.
 
    Customize This Setting:  Not Allowed
 
    Debit Card Usage: Default:  Allowed for the Health FSA.
 
    Customize This Setting:  Not allowed for the plan
    Health FSA Change of
    Status Elections:
Default:  Change of Status election changes are allowed except that elections cannot be
             decreased less than the amount already reimbursed.
 
    Customize This Setting:  Change of Status election changes allowed without limitation
                                           
 
    Health FSA and HSA: Default:  There is no provision for coordinating the Health FSA with any Health Savings Account
             (HSA) coordination.
 
    Customize This Setting:  The Health FSA will coordinate with any HSA to allow only
                                                   Permitted Coverage (e.g., dental care, vision care, etc) for
                                                   those participants eligible to participate in a High Deductible
                                                   Health Plan (HDHP).
                                          
  The Health FSA will coordinate with any HSA to allow only
                                                   Post Deductible Coverage (e.g., the Plan will not pay or
                                                   reimburse any medical expense incurred before the
                                                   minimum annual deductible is satisfied) for those
                                                   participants eligible to participate in a HDHP.
                                             The Health FSA will coordinate with any HSA to allow both
                                                   Permitted Coverage and Post Deductible Coverage for
                                                   those participants eligible to participate in a HDHP.
 
    Health FSA and HRA: Default:  Unless you are also purchasing a Health Reimbursement Account (HRA) document at
             this time, there is no provision for coordinating the Health FSA with any (HRA). If you
             are also purchasing a Health Reimbursement Account (HRA) document please select
             the method of coordination between the Medical Expense FSA and the HRA.
 
    Customize This Setting:  The Health FSA will coordinate with any HRA by requiring
                                                   Medical FSA payment first (e.g. participant shall not be
                                                   entitled to payment/reimbursement under the HRA for
                                                   expenses that are reimbursable under both plans until the
                                                   participant has received his or her maximum annual
                                                   reimbursement under the Medical FSA).
                                              The Medical FSA will coordinate with any HRA by requiring
                                                   HRA payment first (e.g. participant shall not be entitled to
                                                   payment/reimbursement under the Medical FSA for expenses
                                                   that are reimbursable under both plans until the participant
                                                   has received his or her maximum annual reimbursement
                                                   under the HRA).
                                              No coordination between the Medical FSA and any HRA
 

If you intend to include a Dependent Care Reimbursement Plan (DCAP) component in your Cafeteria Plan, please complete the following:
    Dependent Care FSA Annual Limit:  
      The IRS allows up to $5,000 per year. Do you want to limit that amount?
      If Yes, indicate the amount:   $
    Dependent care FSA Default Settings:  
    The following default settings are utilized. To use the default listed, no action is necessary.
 
    If you wish to use a setting other than the default setting, check the box to the left of the item to indicate a customized
    setting is needed. Check ONLY settings you wish to change. Then indicate the customized setting in the location provided.
 
    2 Month Grace
    Period:
Default:  Not allowed for the Dependent Care FSA.
 
    Customize This Setting:  Allowed
 
    Debit Card Usage: Default:  Allowed for the Dependent Care FSA.
 
    Customize This Setting:  Not allowed for the plan

Other/Notes:
Plan Document Creator Contact:  
    (Please specify your contact
    information so that we may
    reach the correct contact
    should questions or the need
    for additional info. arise)
* Name:       
* Phone:      
* Email: