ERISA Group Insurance Summary Plan Description (SPD) Wrap document

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

We value your feedback

How did you hear about us?

Customer Survey

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

Method:

Name of Insurance Carrier(s)

Insurance Carriers

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

Health Insurance Carrier #1

Health Insurance Carrier #2

Health Insurance Carrier #3

Funding Mechanism

Check all that apply

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

Assigned Plan Number

Plan Identification for Reporting Purposes.

Please Choose

Other

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.

Documenting Method

Monthly Measurement Period
Look Back Alternative

Statement of Grandfathered Status

Please choose Yes below if your plan is grandfathered.

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.

Designation Required

Yes
No

Choose Your Plan Options (SPD Module)

Choose one of these three plan document options:

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

Additional Plan Document Options:

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.

Dental Insurance

Vision Insurance

Group Term Life

Accidental Death & Dismemberment

Short Term Disability

Long Term Disability

Accident Insurance

Critical Illness Insurance

Cancer Insurance

Intensive Care Insurance

Other Insurance

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.

How did you hear about us?

Customer Survey

How did you hear about us?

Insurance Carriers

Plan Identification for Reporting Purposes.

IRS Notice 2012-58

Please choose Yes below if your plan is grandfathered.

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

Primary Care Provider

Please include all Supplemental Insurance Carriers by plan.

Supplemental Insurance

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.