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.