[COMPANY NAME] SECTION 125 CAFETERIA PLAN
SUMMARY PLAN DESCRIPTION
Effective Date: [EFFECTIVE DATE]
PLAN INFORMATION
Plan Name: [COMPANY NAME] Section 125 Cafeteria Plan
Plan Sponsor: [COMPANY NAME]
Plan Administrator: [COMPANY NAME or ADMINISTRATOR NAME]
Plan Year: [START DATE] to [END DATE]
Employer ID Number: [EIN]
ELIGIBILITY
Employees eligible to participate in this Plan include: [ELIGIBILITY CRITERIA, e.g., "Full-time employees working 30+ hours per week after 90 days of employment"]
BENEFITS AVAILABLE
This Plan allows eligible employees to pay for the following benefits on a pre-tax basis:
Employee contributions for employer-sponsored health insurance
Optional Benefits (if offered by employer):
Health Flexible Spending Account (maximum annual contribution: $[AMOUNT])
Dependent Care Assistance Program (maximum annual contribution: $[AMOUNT])
[OTHER OPTIONAL BENEFITS]
CONTRIBUTION REQUIREMENTS
Employer-Required Contributions: Premiums for employer-required coverage may be paid pre-tax through this Plan.
Voluntary Coverage: [SELECT ONE: "Premiums for voluntary coverage (employee-elected) may also be paid pre-tax through this Plan" OR "This Plan does not allow pre-tax payment for voluntary coverage"]
Minimum Employee Contributions: [SPECIFY IF THERE ARE MINIMUM EMPLOYEE CONTRIBUTION REQUIREMENTS, e.g., "Employees must contribute at least $XXX annually to participate in the Health FSA" or "There are no minimum contribution requirements for this Plan"]
ELECTION PROCEDURES
New employees: Elections must be made within [NUMBER] days of becoming eligible
All employees: Elections must be made during annual open enrollment
Elections remain in effect for the entire Plan Year unless a qualifying event occurs
QUALIFYING EVENTS
Mid-year election changes are permitted only for qualifying events, including:
Marriage, divorce, or legal separation
Birth or adoption of a child
Death of spouse or dependent
Change in employment status
Change in dependent eligibility
Change in residence affecting coverage
USE-OR-LOSE RULE
Any unused amounts in FSA or DCAP accounts at the end of the Plan Year will be forfeited, except:
[INCLUDE IF APPLICABLE: A grace period until [DATE] is provided for incurring eligible expenses]
[INCLUDE IF APPLICABLE: Up to $[AMOUNT] of unused Health FSA funds may be carried over to the next Plan Year]
CLAIMS PROCEDURES
Submit claims to: [CLAIMS ADMINISTRATOR/ADDRESS]
Claims must include: [REQUIREMENTS]
Submission deadline: [DEADLINE]
Denied claims may be appealed within [NUMBER] days
TERMINATION OF PARTICIPATION
Participation ends upon:
Termination of employment: [SELECT ONE: "Effective on the date of termination" OR "Effective at the end of the pay period in which termination occurs" OR "Effective at the end of the month in which termination occurs"]
Loss of eligibility
Failure to make required contributions
Termination of the Plan
PLAN AMENDMENT OR TERMINATION
The Employer reserves the right to amend or terminate this Plan at any time.
This is a summary of the Plan. The complete Plan Document is available from [CONTACT INFORMATION].
Plan Administrator Signature: _______________________
Date: _______________________