Pre-Tax Documents

Premium Conversion Plan

Premium Conversion Plan Summary Plan Description

Section 125 Election Form

Section 125 Election Form Spanish

DOL Notices

Wrap Plan Document

Wrap Summary Plan Description

FMLA Fact Sheet

FMLA Employee Rights and Responsibilities

ADA Fact Sheet

FLSA Fact Sheet

Health Insurance Exchange Notice

Health Insurance Exchange Notice Spanish

Summary of Benefits and Coverage

Summary of Benefits and Coverage Base Plan

 Summary of Benefits and Coverage High Plan

Summary of Benefits and Coverage Base Plan Spanish

Summary of Benefits and Coverage High Plan Spanish


 Compliance Documents


Pre-Tax Documents

  (Client Name) provides a Premium Conversion Plan to eligible employees. This plan enables eligible employees to elect
to receive part of their compensation in the form of pre-tax benefits. See attached summary plan description and election form for more information.

The Premium Conversion Plan is an Internal Revenue Service (IRS) plan document filed as a Section 125. The (IRS) states that eligible employees may only make elections to the plan during their initial eligibility period, or once a year at open enrollment. Pre-tax benefit choices are binding through the end of the plan year. The following circumstances are some examples of allowable changes you can make during the plan year:

 - Marriage or Divorce
 - Birth or Adoption
- Death of a Dependent
 - Loss of Dependent Status
- Loss of spouse's job where coverage is maintained through his/her employer plan

DOL Notices

The Summary Plan Description (SPD) is a written document that the plan administrator must provide automatically and free of charge to all participants of an ERISA-covered health benefit plan. The SPD explains what coverage the plan offers, how the plan operates, and the rights and responsibilities of participants and beneficiaries. The SPD, in addition to the written plan document, must be provided to all participants. Carrier certificates do not alone satisfy the requirements of the SPD.

For additional information on the SPD and compliance you may refer to the DOL website: http://www.dol.gov/dol/topic/health-plans/planinformation.htm

The Wrap SPD document is used to wrap the required ERISA language around a single policy or plan. For example, the Wrap is used to combine the ERISA language with a medical certificate of coverage (or dental, vision, life, disability). Insurance carriers often include state-mandated provisions regarding coverage but do not always include the required federal ERISA requirements. 

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