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 FSAPlan YearStart* MM slash DD slash YYYY End* MM slash DD slash YYYY Bill To:ClientBrokerPlan Sponsor IRS Business CodeType of Plan*Single-Employer PlanMulti-Employer PlanMultiple Employer PlanType of Return* Regular Report First Report Amended Report Final Report Short Plan YearName of Plan*Plan Number*Collectively Bargained?YesNoPlan Effective Date MM slash DD slash YYYY Does ER maintain ERISA Wrap Doc?YesNoPlan Sponsor ContactPlan Sponsor Contact Phone Plan Sponsor Email Plan Administrator (could be same as Sponsor)Administrator Phone Administrator Email Name of 5500 signer*Medical Insurance CarrierMedical Policy #Medical Plan YearMedical Plan Year - StartStart MM slash DD slash YYYY Medical Plan Year - EndEnd MM slash DD slash YYYY Dental CarrierDental Policy #Dental Policy YearDental Policy Year - StartStart MM slash DD slash YYYY Dental Policy Year - EndEnd MM slash DD slash YYYY Vision CarrierVision Plan #Vision Plan YearDateVision Plan Year - StartStart MM slash DD slash YYYY DateVision Plan Year - EndEnd MM slash DD slash YYYY Life Insurance CarrierLife 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) CarrierTemp 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 CarrierLTD 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) CarrierDeath Policy #Death Plan YearDeath Plan Year - StartStart MM slash DD slash YYYY Death Plan Year - EndEnd MM slash DD slash YYYY Prepaid Legal CarrierPrepaid 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 CarrierStop-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 SponsorPlan Benefit Arrangement Insurance Code Section 412(e)(3) Insurance Contracts Trust General Assets of the SponsorBeginning 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.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
