5500 – New Client Form Service LevelStandard 5500DFVC 5500Prior Year 5500 AmendmentRecreate Prior Year SARPlan Sponsor (Employer) Name* Specific Benefits being Filed* All Employer Benefits (Consolidated) Group Health Group Dental Group Vision Group Term Life Group Disability AD&D FSA Plan YearStart* MM slash DD slash YYYY End* MM slash DD slash YYYY Bill To:ClientBrokerPlan Sponsor IRS Business Code Type of Plan*Single-Employer PlanMulti-Employer PlanMultiple Employer PlanType of Return* Regular Report First Report Amended Report Final Report Short Plan Year Name of Plan* Plan Number*Collectively Bargained?YesNoPlan Effective Date MM slash DD slash YYYY Does ER maintain ERISA Wrap Doc?YesNoPlan Sponsor Contact Plan Sponsor Contact Phone Plan Sponsor Email Plan Administrator (could be same as Sponsor) Administrator Phone Administrator Email Name of 5500 signer* Medical Insurance Carrier Medical Policy # Medical Plan YearMedical Plan Year - StartStart MM slash DD slash YYYY Medical Plan Year - EndEnd MM slash DD slash YYYY Dental Carrier Dental Policy # Dental Policy YearDental Policy Year - StartStart MM slash DD slash YYYY Dental Policy Year - EndEnd MM slash DD slash YYYY Vision Carrier Vision Plan # Vision Plan YearDateVision Plan Year - StartStart MM slash DD slash YYYY DateVision Plan Year - EndEnd MM slash DD slash YYYY Life Insurance Carrier Life Insurance Policy # Life Insurance Plan YearLife Insurance Plan Year - StartStart MM slash DD slash YYYY Life Insurance Plan Year - EndEnd MM slash DD slash YYYY Temporary disability (accident or sickness) Carrier Temp Disability Policy # Temp Disability Plan YearTemp Disability Plan Year - StartStart MM slash DD slash YYYY Temp Disability Plan Year - EndEnd MM slash DD slash YYYY LTD Carrier LTD Policy # LTD Plan YearLTD Plan Year - StartStart MM slash DD slash YYYY LTD Plan Year - EndEnd MM slash DD slash YYYY Death benefits (include travel accident but not Life) Carrier Death Policy # Death Plan YearDeath Plan Year - StartStart MM slash DD slash YYYY Death Plan Year - EndEnd MM slash DD slash YYYY Prepaid Legal Carrier Prepaid Legal Policy # Prepaid Legal Plan YearPrepaid Legal Plan Year - StartStart MM slash DD slash YYYY Prepaid Legal Plan Year - EndEnd MM slash DD slash YYYY Stop-Loss Carrier Stop-Loss Policy # Stop-Loss Plan YearStop-Loss Plan Year - StartStart MM slash DD slash YYYY Stop-Loss Plan Year - EndEnd MM slash DD slash YYYY Other (Benefit & Carrier) Other Policy # Other Plan YearOther Plan Year - StartStart MM slash DD slash YYYY Other Plan Year - EndEnd MM slash DD slash YYYY Are Health Plans considered:Experience Rated ContractNon-Experience Rated ContractPlan Funding Arrangement Insurance Code Section 412(e)(3) Insurance Contracts Trust General Assets of the Sponsor Plan Benefit Arrangement Insurance Code Section 412(e)(3) Insurance Contracts Trust General Assets of the Sponsor Beginning of Year - Total # of Participants*End of Year - Active ParticipantsEnd of Year - Retired or separated participants receiving benefitsEnd of Year - Other retired/separated participants entitled to future benefitsEnd of Year - # of participants (active & COBRA) in Term Life or STDEnd of Year (Multi-employer Only) - Total # of employers obligated to contribute to PlanYour Name* First Last Your Phone Number*Your Email* NotesAdd any pertinent notes that we should know. We may call you to clarify.CAPTCHANameThis field is for validation purposes and should be left unchanged.
