ERISA Documentation Application

ERISA Documentation Application
Legal Name of Business
Enter the name exactly as it appears on tax documents
Business Legal Address

Street Address

Street Address Line 2

CityState

Zip Code
Federal Employer ID Number
Sole ProprietorC-CorporationS-CorporationGovernment AgencyLLC (Limited Liability Company)Other
Primary Contact Person

First NameLast Name
Title of Primary Contact
Email
example@example.com
Phone Number

Area CodePhone Number
Medical InsuranceDental InsuranceVision InsurancePrescription Drug Plan (if not included in your Medical plan)Health Reimbursement Arrangements (HRA)Health Flexible Spending Account (FSA)Group Life InsuranceWellness Programs (when Medical care is provided)Disability BenefitsDisease Specific coverages (IE. Critical Illness plans, etc.)Virtual MedicineOther
PayPalCheck
Complete ERISA 'WRAP' DOCUMENT (Includes POP) $500Premium Only Plan $250Wrap Document Amendment $250
Mail Check Payable to:

Bullock & Associates, Inc.

321 N. Clark; Suite 500

Chicago, IL 60654
Products
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Complete ERISA ‘WRAP’ DOCUMENT (includes POP)$500.00

Premium Only Plan$250.00

Wrap Document Amendment$250.00

Total $0.00
Signature*

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