Determine plan design & effective date Complete Client Transmittal Sheet Communicate plan to employees Return Employee elections to FlexAmerica for processing by deadline Set-up plan checking account Set-up payroll data formats FlexAmerica will pay all plan benefits from a designated checking account. Your Account options are: 1. Benefits may be paid from your operating account, or 2. Benefits may be paid from a benefits account you establish FlexAmerica must be informed of the account number, routing number, bank address and starting check # The signer on the account can be FlexAmerica, or a designated individual at your corporation If the signer is FlexAmerica, please forward a signatory card to FlexAmerica. If the signer is an individual at your office, FlexAmerica will need to obtain their signature so we can laser it onto the checks, or Checks may be mailed to your office for a "manual" signature and distribution Top Flexible Spending Account Transmittal Form completed by If unavailable, contact Telephone No. Type of Firm: CPAATTORNEYACTUARY OTHER Fax No. Shipping Address: Check if new address Firm Address (no P.O. Box) City State Zip Postal Address:(if different) Check if new address Firm Address (no P.O. Boxes) City State Zip Date: Plan Name: Approx. number of participants: DOCUMENT TYPE Cafeteria Plan (Includes Adopting Resolution)   d. Flexible Spending Account Plan $750 e. Premium Only Plan $350 SUPPORTING FORMS PACKAGE (Includes SPD & Election Forms)  EMPLOYEE CAFETERIA COMMUNICATION PAMPHLET*** (see pricing below) Yes(quantity) No TURNAROUND (following the date of receipt until mailing)   Type Business Days Add Normal 5 $ 0 Express-24** 1* $200 *Special language may delay turnaround, but plan will retain Rush or Express priority. **Must be received by 10:30 a.m. ET and will be sent overnight delivery. SPECIAL LANGUAGE Special language requested Note: Additional time may be required for special language modification and checklist entries. Language modification will be charged for consultant time. DELIVERY (delivery costs will be added) (UPS delivery unless otherwise indicated) Overnight Overnight with Saturday delivery 2 business days 5 to 7 business days (UPS) Other SPECIAL INSTRUCTIONS: RERUN FEES* If you wish to make further revisions to the documents after receipt you can retype a single page or have FlexAmerica make the changes for you. Rerun fees apply to variable changes only. Additional charges will be applied for special language modifications. (2) Rerun of Plan and/or SPD   $100.00   NOTE: FlexAmerica reserves the right to use the most efficient correction method - rerun of pages or entire document. EMPLOYEE CAFETERIA COMMUNICATION PAMPHLETS If you wish to have your firm name, address and/or logo imprinted on the back cover, the charge is $80.00 per order. If you would like a logo or other artwork to appear on the pamphlet, please submit camera-ready black and white art. (To reproduce well, art must be solid black, with clear and clean edges, and appear on a white background.) Please allow 2-4 weeks for delivery. Pamphlet Quantity Cost under 200 no charge 200+ $ 1.25 each   plus shipping charges Flexible Spending Account Checklist Name of Employer: (exactly as it is to appear with punctuation) a b. Employer's Address: Street (no P.O. Boxes) City State Zip Telephone Employer's TAX ID No.: a. Plan Number: a.501 502503 504505 Plan Administrator shall be: a. Employer, using Employer's address OR   b. Other(Name) AND, if Other selected c. Use Employer's address d. Use address below   Street (no P.O. Boxes) City State Zip Telephone Plan's Agent for service of legal process is: a. Employer, using Employer's address b. Plan Administrator c. Other(Name) AND   d. Use Employer's address e. Use address below...   Street (no P.O. Boxes) City State Zip Employer's Principal Office a.(State) Plan Information: a New Plan b Amendment and Restatement Plan Name/Title of Document: (exactly as it is to appear with punctuation) a. b. c. Plan Year: a. Begins (month)(day) b. Ends (month)(day) Is first year a short Plan Year? c. Yes, beginning (month)(day) d. N/A   Effective Date(s): a. Initial Effective Date (month)(day)(year) b. This Restatement (month)(day)(year) Employer Entity: a. S Corporation (2% shareholders not eligible) b. Corporation c. Partnership (self-employed (partners) not eligible) d. Sole Proprietorship (self-employed not eligible) e. Governmental Entity or Church f. Non-profit Organization g. Limited Liability Corporation Eligible Class of Employees: a. All Employees who satisfy eligibility requirements b. Salaried Employees only c. Hourly Employees only d. All Employees except:   1. Commissioned Employees 2. Union Employees 3. Leased Employees 4. Part-time Employees, expected to work less thanhours per week 5. Non-resident Aliens 6. Employees not eligible under the Employer's group medical plan 7. Other exclusion (type) Conditions for Eligibility: a. Same as Employer's group medical plan OR     b. For first Plan Year only, anyone employed on the effective date of the Plan is eligible, thereafter: (choose one from d-g below) OR     c. For all years, eligibility is as follows: (choose one from d-g below) d. Date of hire (no service required) e. years after date of hire f. days after date of hire g. months after date of hire AND For Health Care Reimbursement Fund only, eligibility is as follows: h. No Health Care Reimbursement, or eligibility is the same as above for all benefits i. days after date of hire j. months after date of hire k. years after date of hire Entry Date: a. First day of the pay period next following date requirements were met b. Date conditions for eligibility are met c. Dual entry (1st day of Plan Year & 6 months later) d. First day of Plan Year following date requirements were met e. First day of month following date requirements were met f. Same as Employer's group medical plan Compensation received during Plan Year shall be... a. Total cash renuneration b. Base compensation (excludes overtime, commissions, and bonuses) c. Other (type) d. N/A Contributions. Plan will provide for... a. Salary reduction contributions ONLY (no Employer contributions) (skip to 20) b. Employer contributions ONLY (no salary reductions) (answer 19, then skip to 21) c. Both salary reductions AND Employer contributions Employer Contributions. For each Plan Year, Employer will contribute...   N/A a. % of compensation per Participant b. $per Participant c. Discretionary d. Other (type)     AND, the contributions shall be made.. e. At beginning of Plan Year f. Pro rata each pay period     AND, the contributions are convertible to cash g. Yes h. No Note: Option h. may not be selected with 18b. Salary Reduction Election. For each Plan Year Employees may elect to reduce compensation by... a. Up to% each Plan Year b. From% to c. % each Plan Year d. Up to $each Plan Year OR     e. Amounts sufficient to support benefits elected   Benefit Options. Plan to provide... k. Flexible Spending Accounts. (automatically selected)   AND, Maximum salary reduction amount shall be f. N/A (if 21k is chosen, must select 25d) g. $per pay period h. $per Plan Year i. % of compensation Note: Regulations require either a maximum or formula for determining such be stated in the Plan Document. Flexible Spending Accounts will be established for... (check all that apply) k. Health Care Reimbursement Plan l. Dependent Care Assistance AND include account for insurance premium payments m. Yes, include Premium Payment Account - must check applicable coverage below and at question 22 n. No (skip to 24) Premium Payments may be elected for... a. Health insurance (individual AND dependent coverage) OR b. Dependent health insurance ONLY OR c. No group health insurance AND d. Group-term life insurance e. Disability insurance f. Dental insurance g. Cancer insurance h. Vision insurance i. Accidental Death and Dismemberment insurance j. Other (type) Are the health premium payments elected above self-insured by the Employer? a. Yes b. No For Health and Disability Insurance, may Participants seek reimbursement for individual policies through the Premium Conversion Plan? a. N/A b. Yes, at the Administrator's discretion c. No Any forfeited amounts shall be: a. Distributed to Participants per capita b. Donated to charity c. Retained by the Employer Benefit Limitations: (select as applicable) a. N/A-No limitations (skip to 26) b. Group-term life insurance premiums needed to purchase:   1. times compensation   2. $50,000   3. lesser oftimes compensation or $50,000   4. N/A Note: Insurance over $50,000 could result in taxation to employees. c. Disability shall be limited to% of compensation d. $shall be maximum participant allocation to Health Care Reimbursement Fund Note: If not selected, Policy will control. e. Maximum salary reduction to 401(k) Plan may not exceed% of compensation Note: If no selection made, provision of 401(k) Plan will control. Benefit Election Period shall be... a. Theday period prior to each Plan Year b. From theday to 1. day period prior to each plan year c. Established by Administrator in nondiscriminatory manner Is automatic enrollment for insured benefits provided under this Plan? a. Yes b. No Participants who fail to sign a new election form shall... (If 27a has been selected, this item applies only to 21k or l) a. Continue same elections as prior year b. Be considered to have elected not to participate for upcoming Plan Year c. Continue same elections as prior year only for insured benefits Will Affiliated Employers execute this plan? a. N/A or No b. Yes, include signature lines for:   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a second Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a third Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a fourth Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a fifth Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a sixth Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a seventh Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a eighth Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a ninth Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Will there be a tenth Affiliated Employer? a. No b. Yes   1. (Name)   2. (Street)   3. (City/State/Zip)   4. (ID No.) Witnesses to Employer's signature: a.Yes b.No Note: State law may require witnesses to the employer's signature. Supplemental Participation Agreement Requested: (Select "Yes" only if other Employers are affiliated with this Plan) a.N/A - No Supplemental Participation Agreement b.Yes - Supplemental Participation Agreement to be included For a Health Care Reimbursement Plan, terminated Employees shall... a. Continue contributions and reimbursements for the remainder of the Plan Year b. Cease contributions and reimbursements upon termination c. Continue or cease at Participant's election d. N/A-Health Care Reimbursement Plan is not offered For Health Care Reimbursement Plan, new election due to change in family status permitted? a. No b. Yes c. Yes, only if salary redirections to the medical account are increased d. N/A-Health Care Reimbursement Plan is not offered Note: Options a. & c. may reduce Employer's risk of loss. Is a 401(k) plan a benefit under this Cafeteria Plan? a. Yes, name of Plan: b. No or N/A May Participants convert vacation days into Cafeteria Plan benefit dollars? a. Yes b. No Claims for Reimbursement must be filed within a.days following each Plan Year (Applies only to 21k or l) E-mail Address Origination Payroll Company Number of Pay Periods - Group 1 Number of Pay Periods - Group 2 1st and 2nd Pays - Group 1 1st and 2nd Pays - Group 2 Executive Contact Payroll Contact Broker Name Broker Phone FlexAmerica Responsible for 5500 Yes NO FlexAmerica Effective Date Minimum health care acct Signature on Account FlexAmerica Employer Administration Fee by Claims Processing Client Yes NO Checks Mailed to(Drop Down Employer Employee Billing Fees: Document   Billing Fees: 5500   Billing Fees: FSA annual set-up   Billing Fees: FSA Participant Fee   Billing Mode Annual Quarterly Monthly These documents are being printed by FlexAmerica at the direction of the persons named on the transmittal form. Any unanswered questions may result in errors in the plan produced from the information on this checklist. A copy of the checklist and plan document should be reviewed by the appropriate legal or accounting professionals who regularly provide legal or accounting advice to the company named at the top of the checklist. It is understood that FlexAmerica is not engaged in the practice of law and the documents produced are in a format which has been designed by and programmed by our vendor. FlexAmerica is a contracted TPA with this provider who uses an automated system to produce plan documents for its clients. It is understood that FlexAmerica has made NO REPRESENTATION OR WARRANTY OF ANY KIND, expressed or implied, including no warranties or MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, nor is any opinion, expressed or implied, rendered by their attorneys as to the legal effect, sufficiency or tax qualification of any document utilizing our format. Your SSN: Today's Date:   Top Contact Us:info@flexamerica.com