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: Select StateALAK AZARCA COCTDE DCFLGA HIIDIL INIAKSKY LAMEMD MAMIMN MSMOMT NENVNH NJNMNY NCNDOH OKORPA RISCSD TNTXUTVT VAWAWV WIWY     * 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:         Select StateALAK AZARCA COCTDE DCFLGA HIIDIL INIAKSKY LAMEMD MAMIMN MSMOMT NENVNH NJNMNY NCNDOH OKORPA RISCSD TNTXUTVT VAWAWV WIWY          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: All allowable medical expenses Listed medical expenses Health plan deductibles Health plan coinsurance Health plan deductibles and coinsurance 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: Beginning of Plan Year Semi annually Quarterly Monthly Per payroll period Claims dependent    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: Yes No    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: Yes No    The Plan allows a carryover of the balance in a    Participant's Health Reimbursement Account to the    next Plan Year: Yes Yes - limited to dollar amount Yes - limited to multiple of maximum of annual benefit No    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: HRA first Cafeteria plan first None Describe method to coordinate coverage in the Plan with Health Savings Accounts None Permitted Coverage Post Deductible Coverage Both Permitted and Post Deductible Suspended HRA    If any HRA/HSA coordination option other than "None" is    chosen, then those limitations shall apply to: All Participants Only Participants eligible to participate in the HDHP Only Participants enrolled in the HDHP Claims Handling Specify whether the deadline for filing claims is a specified number of days or by a specified date: Within specified number of days after end of Plan Year By a specified time 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: Yes No Specify whether the deadline for filing claims is a specified number of days or by a specified date: Within specified number of days after termination By a specified time 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: Yes No 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.       2½ 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.       2½ 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: