Flexible Spending Account Plan Set-Up

Legal Name of Company Sponsoring Plan:

Business Entity Type:

Principal Business Activity:

Federal Employer Identification Number:
-

Contact Person:
Title:

Street Address (No PO Boxes):

City: State:
Zip:

Phone: Fax:
E-mail:

Effective Date: This Plan will be:

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 Year End:

10.

Employer's Principal Office — This Plan shall be governed under the laws of the:

11.

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

Medical expenses not covered by insurance

Adult/child dependent care expenses

Adoption expenses

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.

12.

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

13.

Total Number of Employees:

14.

Payroll is Prepared:

	In house
	Outsourced (specify payroll company): Other:

15.

16.

Name of agent referring this plan:

17.

Your Comments or Questions:

To submit: Print the completed form and click on the "Home" button at the top of the page for mailing address and/or fax number.

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