ERISA Wrap and POP Document Intake Form

ERISA Wrap and POP Document Intake Form
Please complete the following intake form to generate the employer's Wrap and/or POP document(s).

As you progress through completing the intake form, the form subsequently updates with questions and information necessary to create the Wrap and/or POP document(s) specific to the employer.

You can save your progress at any time by clicking the Save button.

Documents are typically completed within 1-2 weeks.

Thank you for trusting BCS!

Acknowledgment

By completing this intake form you are initiating Benefit Compliance Solutions to generate a Wrap and/or Premium Only Plan document for the named organization. The applicable fee is assessed as directed (unless otherwise negotiated with your Compliance Advisory Program (CAP) contract) upon on completion of the document(s).

This form should be completed by the agency benefits representative, not the employer. However, information requested in the intake form may need clarification from the employer.

Please fill out this form in its entirety. If you are unsure about any of the requested information, please indicate "unsure" or "have questions" and BCS will follow up for clarification.

If you have questions about an employer's situation while filling out the form, please send an email to admin@benefitscompliancesolutions.com.

Thank you!
I acknowledge*

Yes

Benefits Agency Information and Invoicing and Billing
Provide the name of the benefits agency and account manager/advisor.

If Wrap and/or POP document preparation is not included in your CAP contract, please provide instruction for invoicing and billing i.e., invoice agency, invoice employer client etc.
Name of Benefits Agency:*
Agency Employee Name:*
Agency Email Address:*
example@example.com
Invoice and Billing Preference:*

Benefits AgencyEmployer ClientN/A - Document preparation included in Compliance Advisory Program (CAP) contract.
Select Agency (if you do not see your agency below documents are not included in your contract)
Employer's Billing Contact Name:*
Employer's Billing Contact Email:*
example@example.com

Please select which documents you're requesting BCS to create. (Note: If the employer has a Health FSA plan document from a vendor, please use the FSA document instead of creating another POP).*

ERISA Wrap Plan onlyPOP/Cafeteria Section 125 Plan onlyWrap and POP/Cafeteria Section 125 Plan

Medical Benefit Information
Medical - Coverage Type:*
Medical - Carrier / Third Party Administrator :*
Medical - Policy Effective Date:*

MonthDayYear
Date
Medical - Carrier / Third Party Administrator Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Medical - Policy/Contract Number:*
Pharmacy Benefit Manager Name:
Pharmacy Benefit Manager Claims Address;

Street Address

Street Address Line 2

CityState

Zip Code
Pharmacy Benefit Manager Policy / Contract Number:
Paid by Employee:*

Secondary Medical Benefit Information

Please list any secondary medical plans offered in this section. Note: please only list if there is a completely separate plan/carrier, not a different medical plan option with the same carrier listed in the previous step.
Medical - Secondary Coverage Type:*
Medical - Secondary Medical Carrier / Third Party Administrator:*
Medical - Secondary Policy Effective Date:*

MonthDayYear
Date
Medical - Secondary Carrier / Third Party Administrator Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Medical - Secondary Policy/Contract Number:*
Pharmacy Benefit Manager Name:
Pharmacy Benefit Manager Claims Address:

Street Address

Street Address Line 2

CityState

Zip Code
Pharmacy Benefit Manager Policy / Contract Number:
Paid by Employee:*
Provide any additional information, if necessary, regarding the secondary medical plan(s).
Do you offer another medical plan with a different carrier (not another medical plan option, but separate plan/carrier)?

YesNo
Additional Medical Benefit Information

Please list any additional medical plans offered in this section.
Medical - Additional Carrier:*
Medical - Additional Policy Effective Date:*

MonthDayYear
Date
Medical - Additional Coverage Type:*
Medical - Additional Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Medical - Additional Policy/Contract Number:*
Paid by Employee:*
Provide any additional information, if necessary, regarding the additional medical plan(s).

Dental Benefit Information
Dental - Carrier:*
Dental - Policy Effective Date:*

MonthDayYear
Date
Dental - Coverage Type:*
Dental - Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Dental - Policy/Contract Number:*
Paid by Employee:*

Additional Dental Benefit Information

Please list any additional dental plans offered in this section.
Dental - Additional Carrier:*
Dental - Additional Policy Effective Date:*

MonthDayYear
Date
Dental - Additional Coverage Type:*
Dental - Additional Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Dental - Additional Policy/Contract Number:*
Paid by Employee:*
Provide any additional information, if necessary, regarding the additional dental plan(s).

Vision Benefit Information
Vision - Carrier:*
Vision - Policy Effective Date:*

MonthDayYear
Date
Vision - Coverage Type:*
Vision - Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Vision - Policy/Contract Number:*
Paid by Employee:*

Employer Paid Short Term Disability Benefit Information

List policy information if any portion of the STD premium is employer paid.
Short Term Disability - Carrier:*
Short Term Disability - Policy Effective Date:*

MonthDayYear
Date
Short Term Disability - Coverage Type:*
Short Term Disability - Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Short Term Disability - Policy/Contract Number:*
Paid by Employee:*

Voluntary Short Term Disability Benefit Information

List policy information if the STD premium is 100% employee paid.
Voluntary Short Term Disability - Carrier:*
Voluntary Short Term Disability - Policy Effective Date:*

MonthDayYear
Date
Voluntary Short Term Disability - Coverage Type:*
Voluntary Short Term Disability - Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Voluntary Short Term Disability - Policy/Contract Number:*
Paid by Employee:*

Employer Paid Long Term Disability Benefit Information

List policy information if the LTD premium is 100% employer paid.
Long Term Disability - Carrier:*
Long Term Disability - Policy Effective Date:*

MonthDayYear
Date
Long Term Disability - Coverage Type:*
Long Term Disability - Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Long Term Disability - Policy/Contract Number:*
Paid by Employee:*

Voluntary Long Term Disability Benefit Information

List policy information if the LTD premium is 100% employer paid.
Voluntary Long Term Disability - Carrier:*
Voluntary Long Term Disability - Policy Effective Date:*

MonthDayYear
Date
Voluntary Long Term Disability - Coverage Type:*
Voluntary Long Term Disability - Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Voluntary Long Term Disability - Policy/Contract Number:*
Paid by Employee:*

Employer Paid Group Life and AD&D Benefit Information

List policy information if the Life AD&D premium is 100% employer paid.
Group Life and AD&D - Carrier:*
Group Life and AD&D - Policy Effective Date:*

MonthDayYear
Date
Group Life and AD&D - Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Group Life and AD&D - Policy/Contract Number:*

Voluntary Life and AD&D Benefit Information

List policy information if the Life premium is 100% employee paid.
Voluntary Life and AD&D - Carrier:*
Voluntary Life and AD&D - Policy Effective Date:*

MonthDayYear
Date
Voluntary Life and AD&D - Carrier Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Voluntary Life and AD&D - Policy/Contract Number:*
Paid by Employee:

HRA Benefit Information
HRA - TPA:*
HRA - Effective Date:*

MonthDayYear
Date
HRA - TPA Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
HRA - Policy/Contract Number (if applicable):*

HSA Benefit Information

Since an HSA is a non-ERISA benefit, it is listed as a non-ERISA benefit in the Wrap document.
HSA - Vendor (if applicable):
HSA - Effective Date (if applicable):

MonthDayYear
Date
HSA - Vendor Address (if applicable):

Street Address

Street Address Line 2

CityState

Zip Code
HSA - Policy/Contract Number (if applicable):
Contributions by Employee:*

Dependent Care FSA Benefit Information

Since a Dependent Care FSA is a non-ERISA benefit, it is listed as a non-ERISA benefit in the Wrap document.
Dependent Care FSA - TPA*
Dependent Care FSA - Effective Date:*

MonthDayYear
Date
Dependent Care FSA - TPA Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Dependent Care FSA - Policy/Contract Number:*

Flexible Spending / Health FSA Benefit Information
Flexible Spending / Health FSA - TPA:*
Flexible Spending / Health FSA - TPA Claims Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Flexible Spending / Health FSA - Policy/Contract Number:*

Other Benefit Information
Please list any additional benefits and carrier/vendor information below such as:
- Travel Accident Plan
- Employee Assistance Program (EAP)
- Long Term Care
- Standalone Telemedicine/Virtual Care
- Voluntary/Indemnity/Work-site (accident, critical Illness, whole life, cancer, disability, gap insurance, etc.)
Check below if no other benefits apply:

No other benefits apply
Other Benefits:
Should be Empty:

ERISA Wrap and POP Document Intake Form

Benefits Agency Information and Invoicing and Billing

Provide the name of the benefits agency and account manager/advisor.

Employer/Plan Sponsor Information

Medical Benefit Information

Secondary Medical Benefit Information

Additional Medical Benefit Information

Dental Benefit Information

Additional Dental Benefit Information

Vision Benefit Information

Employer Paid Short Term Disability Benefit Information

Voluntary Short Term Disability Benefit Information

Employer Paid Long Term Disability Benefit Information

Voluntary Long Term Disability Benefit Information

Employer Paid Group Life and AD&D Benefit Information

Voluntary Life and AD&D Benefit Information

HRA Benefit Information

HSA Benefit Information

Dependent Care FSA Benefit Information

Flexible Spending / Health FSA Benefit Information

Other Benefit Information