Section 125 Establishment Form
COMPANY INFORMATION
Company Name:
*
The name of the company
Telephone:
*
The business's primary telephone number
Business Address:
*
Street Address, please include unit number here if applicable
Street Address Line 2
City
State / Province
Postal / Zip Code
Benefits Contact:
*
Name of the person who will be responsible for Plan Administration at your company (HR, Owner, etc.)
Email:
*
What is the benefits contact's email address?
Number of Employees
*
Email Address to send ePOP Document to:
*
State of Legal Construction
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Federal Tax ID Number:
*
Is this a Church or Government?
Church
Govt.
None of the Above
Legal Entity Type
Please Select
C-Corp
S-Corp
Sole Proprietorship
Partnership
Non-Profit
LLC
Government Entity
Is this an amendment to the original plan?
*
Yes
No
If yes, what is Original Effective date of the plan?
/
Month
/
Day
Year
Date
What is the effective date of the amendment?
/
Month
/
Day
Year
Date
Current Plan Year Start Date:
/
Month
/
Day
Year
Date
Current Plan Year End Date:
/
Month
/
Day
Year
Date
Waiting Period:
*
Please Select
no wait period
15 days
30 days
45 days
60 days
75 days
90 days
How long do employees have to work here to be eligible?
Hours per Week:
*
How many hours do employees have to work per week to be eligible? (minimum 20)
Months per Year:
*
Please Select
3 months
6 months
9 months
12 months
N/A
How many months per year do seasonal employees have to work to be eligible?
Date of Eligibility:
*
First of Month following waiting period.
Immediately following the waiting period.
Fifteenth of month following waiting period.
Are union employees eligible?
*
Yes
No
Are seasonal employees eligible?
*
Yes
No
If yes, what is the maximum number of consecutive work weeks an employee must work to be classified as seasonal?
Core benefits being offered on a pre-tax basis:
*
Health
HSA
Vision
Dental
Group Term Life
Disability
Cancer
Accident
Bridge/Gap
Hospital Confinement
Other
OPTIONAL HSA AMENDMENT LANGUAGE
Health Savings Account contribution
Effective date
*
/
Month
/
Day
Year
Date
OPTIONAL ENROLLMENT TYPE LANGUAGE
Check all that apply.
Employees are automatically enrolled in the pre-tax plan when first eligible. (Negative/Default Enrollment)
Employee elections roll over from year-to-year. (Evergreen/Rolling Enrollment)
PAY INFORMATION
Pay Schedule
*
Weekly (52 Pays)
Bi-Weekly (26 Pays)
Semi-Monthly (24 Pays)
Monthly (12 Pays)
Other
Next Pay Date after Effective Date
*
/
Month
/
Day
Year
Date
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
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