Forms
The following forms may be useful to assist you with the administration of your plan.
CAUTION: not every form fits every plan. We recommend that you contact your administrator to receive instructions on which forms are most appropriate for your situation. In some cases, none of the following forms will be appropriate and a more customized form will be necessary. Please note that these forms have “Fill in the Blank” Features.
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Primark Benefits New Client Form
Form: Client Information Request
The information we receive from you will let us provide you with the best options for your specific business.
401(k) Salary Deferral Enrollment Application
Form: Generic 401(k) Enrollment
This is a generic enrollment application for a 401(k) Plan. It makes no reference to the plan name. If your plan has specific investment elections that need to be made, this may not be the appropriate form.
Participant Loan Application
Form: Loan Application
Many Plans allow participants and beneficiaries to borrow from the plan. Not all Plans allow loans. First check to see if your plan even allows for loans. There are also many rules about how much can be loaned, what interest rate is applicable, and when the loan must be paid back. These rules will be specific to each plan and will be contained in the Participant Loan Policy. The following is a generic Loan Application.
Rollovers from Outside Plans
Form: Rollovers
Most Plans will allow a participant to roll over benefits and balances that have been accumulated in previous employer’s plan. However, not all plans accept rollovers. This form is a generic explanation in regard to rollovers.
Notice of Termination
Form: Notice of Termination
When an employee terminates employment, he or she may be eligible for immediate distribution. The rules for the timing of the distribution can be different for each plan and should be explained in the Summary Plan Description. In any case, the administrator will need written verification that an employee has terminated employment. The following is a generic form that can be used to inform your administrator at Primark Benefits about an employee’s termination of employment.
Cafeteria Plan Claim Form
Form: Cafeteria Plan Benefits Claim Form
Use this form to submit requests for reimbursement and receipts for all cafeteria Plan Claims:
- Uninsured Medical/Dental/Vision Expenses
- Health Insurance Premium Expenses
- Dependent Care Expenses
Compensation Reduction Agreement – Medical Reimbursement
Form: Election for Medical Reimbursment Plan Benefits
Use this form to elect to have your paycheck reduced by a specific amount each pay period. These funds will be put “on reserve” for the reimbursement of uninsured medical expenses.
Compensation Reduction Agreement – Premium Conversion
Form: Election for Premium Conversion Plan Benefits
Use this form to elect to covert your share of the premium for the employer sponsored health care insurance premium into a “pre-tax” payment.
Compensation Reduction Agreement – Dependent Care
Form: Election for Dependent Care Plan Benefits
Use this form to elect to have your paycheck reduced by a specific amount each pay period. These funds will be used to cover dependent care expenses.