Your Email: (required)

1. Plan Sponsor Full Name:

2. Plan Sponsor EIN # (Federal Tax ID #)

3. Affiliated Companies and EIN #’s: (if applicable)

_______________________________________________________________________________
4. Plan Year Period:

5. Check The Benefits Offered:
HealthLifeLTDSTDADDDentalVision
Other Benefits:

6. Approximate # Of Employees Covered:

7. Do you have a Plan Document?
YESNO
8. Is your Plan Document ERISA compliant?
YESNODont' Know
9. Do you have a Summary Plan Description (SPD)?
YESNO
10. Is your SPD ERISA compliant?
YESNODon't Know
11. If “Yes” to #9, have you distributed this to each participant?
YESNO
12. Have you ever amended your Plan Document or SPD?
YESNO
13. If “Yes” to #12, did you distribute a Summary of Material Modification (SMM)?
YESNO
14. Have you filed a Form 5500 in the past?
YESNO
15. If “Yes” to #14, did you distribute a Summary of Annual Report? (SAR)?
YESNO
16. Are you now, or have you ever been subject to a DOL audit?
YESNO
Leave a brief message with your quote request.