Section 125 & C.O.B.R.A. Outsource Proposal Request

In order to obtain a quote please fill out the following form and click "SUBMIT" below. We will automatically receive your information and begin working on your quote immediately. If you would like to discuss the quote request with us, please contact our office.

If additional information is needed in order to process your quote request, we will contact you.

All fields are required unless indicated optional.

This quote is for:

Flex. Spending Account (F.S.A.) Premium Only Plan (P.O.P.) C.O.B.R.A. Administration Outsource
   
Company Name:
Contact Name:
City:
State:
Zip:
Email Address:
Your Phone Number:
Extension: (optional)
Fax Number:
What is the nature of your business?:
What is your company's Standard Industrial Classification (SIC) ? (Not required) (optional)
When was this company started? (mm / dd / yyyy)
/ /
Do you currently have a Plan? Flex. Spending Account (F.S.A.) Premium Only Plan (P.O.P.) C.O.B.R.A. Administration Outsource
If so, please indicate the current plan administrator. Please also give a brief description of each plan:
How many eligible employees does the firm employ?
How many employees currently participate in FSA or POP? (If quote is desired)
How many employees are currently on COBRA? (If quote is desired)

 
 

 

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