Section I :  General Information

Company Name:

Address:

Phone:

Fax:

Contact Name:

eMail Address:

Section II: Company Information

Total # of Employees:

# of locations:

Where are your locations? (use a new line for each location/city)

Pay Cycle:

# of Pay Cycles per Year:

Section III: Section 125 Information

Do you currently have a Section 125 cafeteria Plan? YES   NO

If Yes, what is the Plan Year?

Check all that currently apply:

   Premium Only Plan                    YES   NO

   Flexible Spending Accounts       YES  NO

   Benefit Bank                             YES  NO 

Section IV : Voluntary Benefits

Place check marks as appropriate in the following columns:

Comments: (anything addition you would like to address)