Request for Section 125 (cafeteria plan) Documents

This is to request Kistler Tiffany Benefits Human Resources Services established a Section 125 (cafeteria plan) Document. Summary Plan Description and Corporate Resolution to adopt the Plan. Please forward the necessary forms to establish these legal documents.

Section 125 Request Information ( All fields are required)

Does the employer have a Flexible Spending Account Plan?

Yes No

Broker Name
What is the name of the Employer?
What is the Employer’s address?
What is the Employer’s Telephone Number?
Who is the Employer’s Contact Person?
What is the Employer’s email address?
Who is the Plan Administrator, if different?
Note: This is not the third party administrator. It is usually the employer but it could be a committee.
What is the Plan Administrator’s address, if different than above?
What is the Plan Administrator’s telephone number, if different than above?
What is the Employer’s Tax I.D. Number?
What is the original Effective Date of the Plan?
What is the Employer’s Entity?
State of Incorporation?
What is the first day of the Plan Year?
What is the last day of the Plan year?
If you previously had a plan in place, what is the Plan Number?
What are the Plan Eligibility Requirements?	For example, employee must work 30 or more hours per week and/or has completed 30 days of employment
What is the Plan Eligibility Date?	the first day of the month after the Eligibility Requirements have been satisfied on the date the eligibility requirements have been satisfied
How many days is the election change / open enrollment period?
How soon must the plan be notified of a status change event?
Benefit Plan 1, 2, 3, 4	For example, Aetna Medical, Delta Dental, FSA, Group Life, etc.
If there are Affiliated Employers participating in the plan, please list them and their addresses.
Who is the third party administrator, if applicable?
Must new elections be made every year?	Yes No
What is the number of vacation days that can be bought under the Plan?
What is the number of vacation days that can be sold under the Plan?

Let Kistler Tiffany Benefits
give your group the edge in
employee benefits planning

As an employer, you are under considerable pressure to provide employee benefits at a reasonable cost. The task of shopping, designing, implementing, and administering benefit plans is complex. That's why you and your employees will benefit from the expertise of Kistler Tiffany Benefits consultants. We provide customized benefit solutions for your employee benefit needs as well as a wide rage of popular voluntary coverages.

Whether you wish to offer employer-paid, employee-paid, or shared contribution programs, Kistler Tiffany Benefits can develop winning strategies for you. Thanks to the volume of business we place and the number of carriers we have relationships with, we are able to provide bids from highly rated companies, many of which are well known to you and some that are new to the Philadelphia regional marketplace. We have direct contact with senior management at several well-known insurers, enabling us to directly negotiate for you. Some major insurers even have representatives dedicated to serving only our accounts.

Request for Section 125 (cafeteria plan) Documents

Let Kistler Tiffany Benefits give your group the edge in employee benefits planning

Let Kistler Tiffany Benefits
give your group the edge in
employee benefits planning