Section I - Company Information

Name of Company:

Address:

Web Address:

City, State ZIP:

Primary Contact:

Email :

Fiscal Year End (month/day)

Phone :

Date Business Established (month/year)

Business Structure

C Corporation

S Corporation

Partnership

LLP

Sole Proprietor

LLC

(is taxed as a

Corporation or a

Partnership? Please check one)

Any predecessor business entities

Yes

No

PSA In The Media

Number of Employees :

Do the owners of this company or their spouses own any other company(ies)?

Yes

No

(If yes, please provide details on ownership and Fiscal Year End in comments section.)

Does the company have prevailing wage projects?

Yes

No

If yes, How much?

Does the company have union employees?

Yes

No

If yes, will they be excluded from the plan?

Yes

No

Does the company have leased employees?

Yes

No

What is the average annual turnover rate among employees?

What is the average tenure of employees?

Do you provide benefit information and enrollment access online?

Yes

No

Do you have a written employee handbook?

Yes

No

Please provide current census

Section II - Existing Insurance Information

HEALTH INSURANCE

Carrier(s) :

Renewal Date(s):

Plan Design:

1.

HMO

POS

PPO

Other

G / NG

1.

HMO

POS

PPO

Other

G / NG

Office/Specialist Co-Pay

1.

/

Prescript Drug Co-Pay:

1.

/

2.

/

2.

/

Deductible/Co-insurance :

Employer Contribution Amount

Single

Family

Other

DENTAL INSURANCE

Carrier(s) :

Renewal Date(s):

Plan Design:

1.

PPO

HMO

BASIC

Benefit Maximum :

Employer Contribution Amount

Single

Family

Other

LIFE INSURANCE

Carrier(s) :

Renewal Date(s):

Plan Design:

1.

Flat Amount

X Salary (check one)

Amount

2.

Flat Amount

X Salary (check one)

Amount

Employer Contribution:

Amount

dollar

percent (check one)

DISABILITY INSURANCE

Carrier(s) :

Renewal Date(s):

Plan Design:

Waiver Period

Monthly Benefit

% to $

Own Occ Definition:

2 years

5 years

To Age 65

Employer Contribution:

Amount

dollar

percent (check one)

Do you provide supplemental disability for owners/executives?

Yes

No

OTHER INSURANCE

Please List:

Please provide plan summary, most recent invoice and renewal letter (if applicable).

Section III - Existing/Prior Retirement Plan Information

Does the company have or ever had a retirement plan?

Yes

No

What is the existing plan type?

SEP

Money Purchase

Defined Benefit Pension

401(k)

Simple IRA

Simple 401(k)

403(b)

Safe Harbor 401(k)

Other

Profit Sharing (check one)

Basic (includes integrated)

Age Weighted

Comparability

Plan Year End:

Existing Plan Assets:

Number of Employees:

Eligible:

Participating:

Estimated Annual Contributions

Employee:

Employer:

Contribution Frequency

weekly

monthly

other

Method of transmission to record keeper

Institution where existing assets are invested

What was the prior plan type?

SEP

Profit Sharing

Money Purchase

Defined Benefit Pension

Simple IRA

Simple 401(k

Other

401(k) if checked, date assets distributed:

Please provide Plan Document, Adoption Agreement, Summary Plan Description and most recent 5500 Filing

Section IV - Existing Section 125 Plan Information

Does your company currently offer a Section 125 plan?

Yes

No

If yes, premium only plan (POP)?

Yes

No

Does your company currently offer Medical, Dependent Care or Commuter Reimbursement accounts?

Yes

No

If yes, provide the following:

Annual Maximum for medical reimbursement:

Annual Maximum for depending care:

Annual Maximum for parking benefit:

Annual Maximum for transit benefit:

Does your company currently offer a Health Reimbursement Account (HRA)
or Health Savings Account (HRA)?

Yes

No

Current Plan Administrator (TPA)

Name:

Address:

Contact:

Phone:

Please Provide Plan Documents, Summary Plan Description and TPA Service Agreement.

Section V - Employment Benefit Objectives