Basic Company Info

Biographical Information

  • 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

  • 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?

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:

  • Benefit type

  • Insurer or TPA

  • Insured or self-insured

  • Unfunded status for purposes of ERISA

Eligibility

  • 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 Administration

  • 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 Administration

  • 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?

Other FSA Administration Questions

  • 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?

Continuation Coverage

  • Self-administered or TPA-administered

  • COBRA TPA contact information (address, phone)

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