• 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 Your Progress button.

    Step 1: Select Save your Progress
    Step 2: On the Jotform “pop-up” select Skip Create an Account at the bottom of the pop-up.
    Step 3: Enter the preferred e-mail to receive an access link to the Jotform being completed.
    Step 4: Check the inbox of e-mail entered for access to the Save your Progress link and the complete Jotform.
    (Note, if the link is not received timely, check spam before requesting Jotform to resend the link.)

    Documents are typically completed within 1-2 weeks.

    Thank you for partnering with 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!

     

  • 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. )
  • Invoice and Billing Preference:*

  • Please note our process:

    The employer client will be billed at the email address provided below within 72 hours of the document being delivered to the agency.
  • Please select which documents you're requesting BCS to create. (Note: If the employer has a Health FSA or DCAP plan document from a vendor, please use that FSA document instead of creating another POP).*

  • Employer/Plan Sponsor Information

  • In the event of a legal request or lawsuit, is the HR Contact Title above the correct position to address for such legal matters?*
  • Format: (000) 000-0000.
  • Is this request to establish a New Wrap Plan or to Amend/Restate an existing Wrap Plan?*
  • Original Effective Date:*
     - -
  • Is this request to establish a New POP Plan or to Amend/Restate an existing POP Plan?*
  • Original Effective Date:*
     - -
  • Plan Year Start Date:*
     - -
  • Is this a short plan year?
  • Plan Year End Date:*
     - -

  • Who is subject to COBRA? - DOL's An Employer's Guide To Group COBRA

    COBRA generally applies to employers that had at least 20 employees on more than 50 percent of its typical business days in the previous calendar year. Both full and part time employees are counted to determine whether a plan is subject to COBRA.

  • Types of Eligible Dependents:*

  • This applies to a client that is an Applicable Large Employer (ALE) under the Affordable Care Act (ACA) (generally, an average of 50 FT employees and equivalents in the prior calendar year).

    There are two approved methods to determine FT employee status for the purposes of ACA:

    1. The monthly measurement method (MM).
    2. The look-back measurement method (LBMM).

    The client will likely know if they use the LBMM because they are tracking employee hours, typically in coordination with their payroll system/vendor. 

  • Check all coverages that apply:*
  • Check all coverages that are paid on a pre-tax basis or included in the §125 Plan:*
  • Check all coverages that apply:*

  • Medical Benefit Information

  • Medical - Policy Effective Date:*
     - -

  • 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 Policy Effective Date:*
     - -
  • Do you offer another medical plan with a different carrier (not another medical plan option, but separate plan/carrier)?

  • Additional Medical Benefit Information

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

  • Dental Benefit Information

  • Dental - Policy Effective Date:*
     - -

  • Additional Dental Benefit Information

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

  • Vision Benefit Information

  • Vision - Policy Effective Date:*
     - -

  • Employer-Paid Short Term Disability Benefit Information

    List policy information if any portion of the STD premium is employer paid. If the employer fully pays for and self-insures the disability plan, it is not an ERISA plan but a payroll practice that should not be included in the ERISA wrap document. 
  • Short Term Disability - Policy Effective Date:*
     - -

  • Voluntary Short Term Disability Benefit Information

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

  • Employer-Paid Long Term Disability Benefit Information

    List policy information if any portion of the LTD premium is employer paid. If the employer fully pays for and self-insures the disability plan, it is not an ERISA plan but a payroll practice that should not be included in the ERISA wrap document.  
  • Long Term Disability - Policy Effective Date:*
     - -

  • Voluntary Long Term Disability Benefit Information

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

  • 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 - Policy Effective Date:*
     - -

  • Voluntary Life and AD&D Benefit Information

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

  • HRA Benefit Information

  • HRA - Effective Date:*
     - -

  • HSA Benefit Information

    Since an HSA is a non-ERISA benefit, it is listed as a non-ERISA benefit in the Wrap document for ERISA employers.
  • HSA - Effective Date (if applicable):
     - -
  • Does the employer contribute?”*

  • DCAP/Dependent Care FSA Benefit Information

    Since a Dependent Care Assistance Program (DCAP/DCFSA) is a non-ERISA benefit, it is listed as a non-ERISA benefit in the Wrap document for ERISA employers. 
  • Dependent Care FSA - Effective Date:*
     - -
  • Is there a grace period for the Dependent Care FSA?”*

  • Health FSA Benefit Information

  • Is there a grace period or carryover for the Flexible Spending Account/Health FSA?*

  • 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 insurance (LTCi)
    • Standalone Telemedicine/Virtual Care
    • Voluntary/Indemnity/Work-site (accident, critical Illness, whole life, cancer, disability, gap insurance, etc.)
  • Should be Empty: