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)

Healthcare FSA TPA contact information (address, phone, website)

Annual contribution maximum

Minimum permissible annual contribution

What forfeiture reduction feature does the plan use (2 1/2 month grace period, fixed-dollar carryover, IRS maximum inflation-adjusted carryover)?

Dependent care FSA TPA contact information (address, phone, website)

Minimum permissible annual contribution

Is 2 1/2 month grace period for incurring new claims provided?

Does the plan have a dependent care spend-down feature?

Is the rule of proration used?

How long do active employees have to submit claims?

How long do terminated employees have to submit claims?

Is there a different deadline for grace period claims?

Dependent care FSA TPA contact information (address, phone, website)

Minimum permissible annual contribution

Is 2 1/2 month grace period for incurring new claims provided?

Does the plan have a dependent care spend-down feature?

Self-administered or TPA-administered

COBRA TPA contact information (address, phone)