SECTION A: GENERAL PLAN INFORMATION
1. Plan Sponsor (Employer’s complete legal name) (“Client”) __________________________________________________________________________________________
2. Business type Corporation S-Corp. Sole Proprietor Partnership LLC Not-for-Prot Government Religious
3. Federal Employer Identication Number (must be nine digits.)
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4. Employer’s principal oce: This Premium Only Plan shall be governed under the laws of the State Commonwealth _____________________________
5. Legal name(s) of aliated company(ies) that will be covered by this Plan
_______________________________________________________________________________________________________________________________________________
6. Eective date of the Plan (check one)
a. A new Section 125 Premium Only Plan eective as of (date) ______________________
b. An amendment and restatement of an existing Section 125 Plan (transfer of Premium Only Plan from your current administrator)
(1) Effective date of original plan _______________________
(2) Eective date of amended and restated plan _______________________
The eective date should be the beginning of the rst payroll period for which employee contributions will be converted to pre-tax. It is not necessary for the eective date to coincide with the rst day of the Plan Year (short
Plan Years are permitted in the rst Plan Year). Per IRS Regulations, all employee communication/election information must be distributed and the plan document must be signed prior to the eective date.
7. Plan year: The rst plan year for this Premium Only Plan will be a (check one)
a. 12-consecutive-month period beginning (date) ______________________ and ending (date) ______________________
b. Short plan year beginning (date) ______________________ and ending (date) _______________________
The Plan Year usually coincides with the renewal date of the insurance plan, calendar year or company scal year.
8. Benets: All benets listed below may be included in the Premium Only Plan, whether you currently oer them or not.
• Health Insurance premiums, including major medical, accident, cancer and critical illness, dental, vision, and hospital indemnity. However, insurance
products with a return-of-premium feature cannot be deducted on a pre-tax basis.
• Group-term life insurance (up to $50,000 including any employer provided coverage)
• Health Savings Accounts contributions that are made through payroll deduction
• Disability insurance (although most tax advisors would advise against this because any disability benets received would be taxable to employees)
9. Total number of employees _____________________
SECTION B: ADMINISTRATOR (Indicate the name and address of the person within the company responsible for plan administration. The application should be signed by an authorized
representative of the company. Reminder: Please do not start pre-tax deductions until you have received the Administrative Kit and signed the Plan Document from WageWorks.)
Plan administrative contact ____________________________________________________ Title _____________________________________________________________
Mailing address (No PO boxes) _____________________________________________________________________________________________________________________
City, State, Zip ____________________________________________________________________________________________________________________________________
Phone _________________________________________ Fax ___________________________________ Email _________________________________________________
WageWorks will be the plan service provider, but will not be the Plan Sponsor or Plan Administrator. This Agreement will become eective on the “Eective Date of the Plan.” It will continue for an initial term of one year
beginning with the Eective Date, or the Amendment and Restatement Date, and continue thereafter for successive one-year terms (“Renewal Terms”) or until terminated by either party upon 90 days prior written notice.
The one-time Implementation Fee must be enclosed with this Application. For each Renewal Term, Client agrees to pay an Annual Compliance Service Fee billed at the end of each Plan Year.
Implementation Fee $ _____________________ (call for quote)
Annual Compliance Service Fee $ ______________________ (billed at the end of each Plan Year end)
Client signature ________________________________________________________________________________________ Date ______________________
This Application and Implementation payment must be received by WageWorks at least 15 business days prior to the Eective Date.
Check enclosed for $ _____________________ (payable to WageWorks, PO Box 870725, Kansas City, MO 64187-0725)
Charge my credit card for $ _____________________ VISA MC AMEX Discover Expiration date ______________________
Credit card number _____________________________________________________ Name on card ____________________________________________________
SECTION C: REFERRAL SOURCE (TO BE COMPLETED BY REFERRING INDIVIDUAL)
Name of referral source ______________________________________________________ Aliated company ________________________________________________
Address (No PO boxes) _____________________________________________________________________________________________________________________________
City, State, Zip ____________________________________________________________________________________________________________________________________
Phone ______________________________________ Fax _______________________________________ Email ________________________________________________
The referring company or its representative may earn a fee for services performed in connection with the implementation of this plan.
Scan and email this completed form to EZPOP@wageworks.com or FAX to 877-769-0173
Questions? Call 800-876-7548 (Weekdays, 8 a.m. – 5 p.m. Central)
