Request for Section 125 Plan Documents

This is to request NetPay USA, Inc. complete a Corporate Resolution establishing a Section 125 Premium Conversion Plan or Flexible Spending Account (FSA) Plan. I understand that the completed Plan Document, Premium Conversion Plan Description, Medical FSA Document & Plan Description (if chosen), Dependent Child Care FSA Documents and Plan Description (if chosen), Administrative Forms, Administrative Handbook, and Resolution to Adopt the Plan are to be returned to me within approximately two weeks. I further understand that the preparation fee includes follow-up contact, initiated by me, to explore any related questions. YOUR INFORMATION IS SAFE! Information supplied on this form is used for the purposes of this transaction only as stated.

Documents Requested

Choose one package and fill out the section(s) as indicated.
ALL orders require Purchaser Information and Employer Information For Documents.
Shipping and Handling for all documents is an additional charge of $15.00 per order.

Premium Conversion Plan Document Only (section 1)

$ 99.00

Medical Expense Reimbursement Plan Document Only (section 2)

$ 99.00

Dependent Care Reimbursement Plan Document Only (section 3)

$ 99.00

Premium Conversion Plan and Medical Reimbursement Account (sections 1 & 2)

$198.00

Premium Conversion Plan and Dependent Care Reimbursement (sections 1 & 3)

$198.00

Medical Reimbursement Account & Dependent Care Reimbursement (sections 2 & 3)

$198.00

Premium Conversion Plan, Medical Reimbursement & Dependent Child Care
(sections 1, 2, & 3)

$249.00
(Save $49.00)
Other Purchase Options
Select optional items below

Annual Maintenance Agreement

$ 49.95

Plan Summary On Disk

$ 10.00

** RUSH Processing
Call 941-755-3373 or 888-755-3373 NOW for Rush service.

$ 29.95
Purchaser Information 
First Name (required)
Last Name (required)
Company (required)
Address (required)
City (required)
State (required)
Zip Code (required)
Phone (required - in case we have questions about your order)
Fax
E-Mail (required - for order confirmation notices)
Employer Information For Documents 
First Name (required)
Last Name (required)
Company (required)
Address (required)
City (required)
State (required)
Zip Code (required)
Phone (required)
Fax
E-Mail

(required) Form of Business:    S Corporation C Corporation   LLC   Partnership
                                                 Sole Proprietorship   Non-Profit 501(c)(3)

(required) Employer Federal ID#: State of Inc.:

How many employees are in your company? (required) 

Legal name(s) of affiliated company(ies) that will be covered by the plan:
Name of Plan Administrator: (Employer unless otherwise listed)
Name:
Address:
City/ST/Zip:
Phone:

SECTION 1:  Prepare Premium Conversion Plan Documents ($99.00) 5 Questions

1. Types of Benefit Plans To Be Offered: (check all that apply)

Health Insurance Dental Insurance Vision Insurance Group Term Life to $50,000
Accident Insurance Cancer Insurance Other

2. Effective Date will be:

a new plan effective date as of (date)

An amendment / restatement* of a previously established Section 125 as of (date)

*If this is an amendment and restatement, state the effective date of the original plan:

3. Plan Year - The first plan year will be:

a 12 consecutive month period beginning (date) and ending (date)

a short plan year beginning (date) and ending (date)

4. Eligibility Requirements: All employees who work more than hours per week.

5. Waiting Period: employees can participate the first day of the month following days of employment.
SECTION 2: Prepare Medical Flexible Spending Account (FSA) Plan Documents ($99.00) 1 Question

1. Choose an annual limit for the Medical FSA: $1,000 year $2,000 year Other: $ year
SECTION 3: Prepare Dependent Child Care FSA Plan Documents ($99.00) 1 Question

1. The IRS allows up to $5,000 per year. Do you want to limit that amount?
If yes, indicate maximum $

From the order review page there are three options to finalize your order:
     1. Proceed to the secure on-line payment form.
     2. Print the order review page, complete the credit card section and fax the form to NetPay USA 941-795-4802.
     3. Print the order review page and fax it with a copy of your check to NetPay USA 941-795-4802. Please make check payable to NetPay USA.

NetPay USA, Inc.
P.O. BOX 14670
Bradenton, FL 34280-4670
Voice: 941-755-3373 or 888-755-3373
Fax: 941-795-4802
Email: Pam@NetPayUSA.com

 Copyright(c) 2002 NetPay USA, Inc.
All Rights Reserved