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Application Med105 Plan

Name of Business:
Name of Owner:
Prefix:
First Name:
Last Name:
Address:

City:
State:	Zip:
Telephone:
Fax:
eMail Address:
Calendar Fiscal Year Ending
Form of Business		Benefits Selection
Medical Insurance Premiums		Sole-Proprietorship (Schedule C)
Prescription Drugs		Corporation
Eye Care		S Corporation
Care Providers		Limited Liability Company
Out of Pocket Deductibles		Partnership
Dental Premiums and Care
Maximum Benefit per employee per year: $
Number of Employees Full/Part time:

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Med 105
A Medical Reimbursement Plan, as authorized by Internal Revenue Code Section 105, can save the small business owner several thousand dollars every year. more