Premium Only Plan – Questionnaire & Document Generator Premium Only Plan – Document Questionnaire 1. Complete Questionnaire 2. Review & Generate Document Employer Information Employer Company Name * Employer EIN * Employer Organization Type * Select type… Corporation Limited Liability Company Partnership S Corporation Sole Proprietorship Non-Profit Organization Estate Professional Corporation Governmental Entity Church Employer Organization State * The questionnaire does not include a field for the Employer’s mailing address, but the Plan Document, Adoption Agreement and Summary Plan Description all require one. Please provide it below. Employer Street Address * City * State * ZIP * Affiliates (if applicable) An affiliate generally means: subsidiaries which are owned (at least 80% ownership) by the plan sponsor, or other companies which are owned (at least 80% ownership) by a parent company which also owns 80% of the plan. Are there any Affiliated Employers participating in this Plan? Yes No List Affiliate Name(s) — one per line Document Information Would you like to add a custom appendix item to the table of contents? If unsure, choose No. Yes No Appendix Title Appendix Content Plan Information Is this Plan new or a restatement? * If this is a brand-new plan for your company, select “New.” If you are amending and restating a previous plan, select “Restatement.” New Restatement Plan Year Start * Should be consistent with the plan year for other group benefits, if possible. Do not back-date. Plan Year End * Original Effective Date Amended and Restated Date Short Plan Year? Yes No Renewal Year Start The date the Plan Year that follows the short plan year will start. Renewal Year End The date the Plan Year that follows the short plan year will end. Plan Benefits Does your plan offer the following benefits? Elections and Plan Options Employee Elections * Select… Election Required First Year Only Election Required Each Plan Year No Election Required, May Opt-Out Include Participant Election Forms Yes No Allow Change of Status if employee Full-Time status drops below 30 hours? Yes No Allow Change of Status if employee is eligible for a Special Enrollment or Annual Open Enrollment Period in a qualified Health Plan within a Marketplace? Yes No Include FMLA Language? Yes No I understand that this questionnaire is provided for informational purposes only, does not constitute legal, tax, or benefits advice. Generate Plan Document → 📄 Section 125 Premium Only Plan (Generated) ← Back to Edit 🖨 Print / Save as PDF
