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

Legal names of the other participating employers

Plan name

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?

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 type

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

Waiting period

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)