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Client Information

Please complete and submit the Client Information form.

Which role describes you best?

Select an option *

I am an employer

I am a broker/agency representing my employer client(s)

Other

Brokerage/Agency Company Name

How many of your clients might use our services?

Employer Information

Company/Employer Legal Name

First name

Last name

Phone

Street Address

Address Line 2

State

City

Zip code

Insurance Broker Name

Insurance Broker Company

Additional Information

Do you need assistance with a Section 125 Cafeteria Plan Document? *

Yes

Unsure

EIN

Number of Employees

Original Effective Date

Plan Year / Renewal

Are there any other employers participating in this benefit plan?

Yes

Unsure

Pre-Tax Benefits offered:

Medical

Health Savings Account Contributions

Dental

Vision

Flexible Spending Account

Does the Plan Sponsor use a TPA for administering the FSA benefit?

Yes

Unsure

FSA Administrator Name

FSA Administrator Phone

FSA Administrator Address

Address Line 2

State

City

Zip code

Does the FSA run on the same plan year as the major medical benefits?

Yes

Unsure

Which of the following does the employer allow at the end of the FSA plan year?

Use-it-or-lose-it. All dollars are forfeited if not used.

Roll-over. Any dollars remaining at the end of the plan year are carried over to the next year up to the IRS maximum carryover amount.

Grace Period. Any claims incurred in the 2.5 months following the plan year will be attributed to the previous year.

Thank you for submitting your information!

StanleyKup Compliance is not engaged in the practice of law or rendering tax advice. Should legal advice be sought, a separate engagement letter must be adopted specifying the scope and nature of the legal work performed.

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