Premium Only Plan Application

Click Here for Printable Version
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:
What is the sum of 4 and 1?