Request for Section 105 Insurance and Medical Expense Reimbursement Plan Documents

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.).

First Name *

Last Name *

Company Name *

Address *

City *

State

Zip Code *

Phone *

Fax

E-Mail *

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

Deductible Gap Questions:

If this plan is used with a High Deductible Health Plan please answer the following questions:

Single Deductible

Employee pays: $

HRA Plan pays: $

Family Deductible

Employee pays: $

HRA Plan pays: $

Funds Availability:

Will this full amount be available in a lump sum or will the benefit accumulate monthly?

If entire HRA benefit is available on the first day of the Plan Year, choose Lump Sum/Annual. Most Deductible Gap Plans are Annual. It is typical for the Comprehensive HRA benefit to be contributed on the first of each month.

Monthly
Lump Sum/Annual

Protected Health Information Designee

Please name the person who will be responsible for the proper handling of medical information protected under HIPAA law:

PHI Person: *

QSE HRA

Choose Your QSE HRA Options

Premium Only Benefit or
Premium and/or all allowed IRS 213(d) Medical, Dental, and Vision expenses.

Allowed Benefit Limits

Please Choose Below and Enter Amounts

Use the annual Maximum IRS allowed benefit of $6150 for Employee Coverage, and $12450 for Eligible Dependents (annually)

- OR -

Employee Limit and Eligible Dependent Limit.

For Employee Only (anually) $

For Employee and Eligible Dependents (annually) $

Carryover of Unused Funds:

Will unused funds carryover to the next Plan Year?

Are unused HRA funds allowed to Carry Over?

We value your feedback

How did you hear about us?

Customer Survey

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

Method:

Choose Your Plan Options (Hybrid HRA)

Choose one of these three plan document options:

Deluxe Binder - New Qualified Small Employer (QSE) HRA Plan Document PDF and Printed plan document in 3 ring professional binder shipped via Priority Mail 249.00

Receive both the printed document and binder AND free PDF email version.

Basic PDF Option - Qualified Small Employer (QSE) HRA Plan Document - PDF email 199.00

PDF Document Processed Quickly and Sent Via E-Mail

Update PDF option - Update an Existing Core QSE HRA Plan Document - PDF email 199.00

This option only available to existing Core Documents clients who had a premium only HRA before ACA.

Additional Plan Document Options:

Plan Document. SPD. Administrative Sections & Forms on CD mailed 25.00

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

Rush Order - automatically queued up for priority processing 25.00

I may be interested in more information about outsourcing HRA plan administration 0.00

.00

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.

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.

If this plan is used with a High Deductible Health Plan please answer the following questions:

Choose One and/or add details in Notes (EX: HRA pays In-Network Deductibles Only, HRA pays Deductibles and Co-Pays)

Amount of Deductible the Employee is responsible to pay either before or after the HRA benefit is received.

Amount of Deductible the HRA Plan will pay either before or after the Employee pays their portion.

Choose One and/or add details in Notes (EX: HRA pays In-Network Deductibles Only, HRA pays Deductibles and Co-Pays, HRA will pay after one covered family member reaches single deductible, HRA will reimburse $500 per member max 3)

Amount of Deductible the Employee is responsible to pay either before or after the HRA benefit is received.

Amount of Deductible the HRA Plan will pay either before or after the Employee pays their portion.

Will this full amount be available in a lump sum or will the benefit accumulate monthly?

If entire HRA benefit is available on the first day of the Plan Year, choose Lump Sum/Annual. Most Deductible Gap Plans are Annual. It is typical for the Comprehensive HRA benefit to be contributed on the first of each month.

Please name the person who will be responsible for the proper handling of medical information protected under HIPAA law:

Please name the person responsible for the Protected Health Information (PHI) for HRA Plans and Section 125 Health FSAs.

Please Choose Below and Enter Amounts

Will unused funds carryover to the next Plan Year?

Will unused HRA funds be allowed to rollover from the previous Plan Year to the New Plan Year?

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.