Request a Proposal
Client/Prospect Name:
Office Location(s) (state):
Nature of Business:
# of Eligible EE's:
Contact Name:
Email Address:
**
Phone # :
Mailing Address:
Send proposal via:
Mail
Email
Fax :
Proposal Due Date :
Proposed Effective Date:
Request proposal(s) for:
Premium Only Plan (POP)
Flexible Spending Account-Healthcare and/or Dependent Care Account(s)
Direct Reimbursement Dental
Is
Flex
A
merica
responsible for reporting & testing?
N/A
Yes
No
Is there an existing plan in place?
N/A
Yes
No
If yes, Current Administrator:
Reason for Review:
Who is responsible fo runout of current plan?
N/A
Current Admin
FlexAmerica
Plan
may not
be in compliance regarding past 5500's
Where did you hear about
Flex
A
merica
?
Additional Comments:
** A copy of this email will also be sent to your email address (above) for your records