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Premium Only Plan Application

Company Profile




















POP Plan Details





Participation in Plan Begins













If the number of Minimum Hours is not indicated, it will by default be 30 hours (per health care reform, the number cannot be higher than 30).


Participation check the benefits to be included under your Section 125 Cafeteria Plan:








Employer intends this Plan to qualify as a "Simple Cafeteria Plan" for purposes of Code Section 125(j):

Employer uses "Top-Paid Group" Election for 401(k) Nondiscrimination Testing purposes:


Please add 6 and 2.