Basic Company Info
Company legal name as it would appear on a tax filing
DBA or trade name, if any
Department (or job title, if no department) most likely to handle a significant benefits-related issue or complaint
Company phone number for benefits-related issues, or main number if none Federal EIN
Street Address, Suite/Floor/Etc., , City, State, Zip Code
Other Participating Employers
Legal names of the other participating employers
Basic ERISA Plan Details
ERISA plan number (5XX)
Plan document effective date
Original effective date of ERISA plan
ERISA plan year
Benefit election year
Any benefits provided under a different ERISA plan?
Benefits & Coverages
Classification of Benefits & Coverages
Non-ERISA benefits (HSA, dependent care FSA, qualified transportation, identity protection, etc.)
Cafeteria plan benefits (health FSA, dependent care FSA, adoption assistance, etc.)
Coverages with employee pre-tax premiums
Coverages with employee after-tax premiums
Benefit & Coverage Summary Table
Complete list of all benefits and coverages provided under the ERISA plan, including:
Insurer or TPA
Insured or self-insured
Unfunded status for purposes of ERISA
Any non-employees or retirees eligible (other than through COBRA or state continuation)?
Any eligibility differences between benefit types or company divisions or types of employees?
Any differences in eligibility among the various benefits of the plan?
Any differences in eligibility among company divisions or participating employers or employee classes?
Hours threshold for full-time or benefits-eligible status
Coverage effective date (first of the month or middle of the month)
Rehire rules (eligibility and elections)
Domestic partner eligibility
Child eligibility (age-out, dependent grandchildren, children of domestic partners)
Self-administered or TPA-administered
COBRA TPA contact information (address, phone)