Federal Employer I.D. #:         -  

Street Address:     

City:  State: Zip:

Telephone: Fax:

Email:

Effective Date of this Plan:
A.  A new plan effective as of (date):
B.  An amendment and restatement of a previously established Section 125 Plan of the employer.

    1. This amendment and restatement is effective as of (date): 

    2. State the effective date of the original plan:                        
  
    3. State the plan number (consult your last Form 5500          
        for this number assigned to your plan):

Plan #: 502 501 503 504 505 506 507 508 509 510 511 512 513 514 515 (if no plan # selected, default is 502).  Plan Year End:

Waiting Period:  Date of Hire
                            1st of month following days
                            Other: 

Eligibility:  All Full-time Part-time Both employees who routinely work 30 32 35 36 40 hours or more per week.

Employer's Principal Office:  This Plan shall be governed under the laws of the:  
   Select: State of Alabama State of Alaska State of Arizona State of Arkansas State of California State of Colorado State of Connecticut State of Delaware District of Columbia State of Florida State of Georgia State of Hawaii State of Idaho State of Illionis State of Indiana State of Iowa State of Kansas Commonwealth of Kentucky State of Louisiana State of Maine State of Maryland Commonwealth of Massachusetts State of Michigan State of Minnesota State of Missouri State of Montana State of Nebraska State of Nevada State of New Hampshire State of New Jersey State of New Mexico State of New York State of North Carolina State of North Dakota State of Ohio State of Oklahoma State of Oregon Commonwealth of Pennsylvania State of Rhode Island State of South Carolina State of South Dakota State of Tennessee State of Texas State of Utah State of Vermont Commonwealth of Virginia State of Washington State of West Virginia State of Wisconsin State of Wyoming

Benefits: The benefits selected below shall be included in the Plan:

Health and other insurance (select coverages below):

   Health insurance
   Dental insurance
   Group-term life insurance*
   Disability insurance**
   Vision care insurance
   Cancer insurance
   Critical illness insurance
   Accidental death/dismemberment insurance

Other (specify):  

* Group-term life insurance up to $50,000 coverage.
** If disability insurance is paid for on a pre-tax basis, any benefits received are taxable to the employee.
     Under most circumstances, it is recommended that disability insurance not be included.

Legal Name(s) of Affiliated Company(ies) that will be covered by this Plan:
  
           

           

           

Total Number of Employees:

Payroll is Prepared:

      In house (specify accounting software)

             Peachtree Quicken Other, please specify   Other:

      Outsourced (specify payroll company) ADP CBIZ Payroll Intuit Paychex QuickBooks Other, please specify

       Other:

Questions: Click here to contact us.