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
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Federal Employer ID Number
Type of Organization (Select Only One)
Sole Proprietor
C-Corporation
S-Corporation
Government Agency
LLC (Limited Liability Company)
Other
Primary Contact Person
First Name
Last Name
Title of Primary Contact
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Check The Coverages Below That Your Company Offers:
*
Medical Insurance
Dental Insurance
Vision Insurance
Prescription Drug Plan (if not included in your Medical plan)
Health Reimbursement Arrangements (HRA)
Health Flexible Spending Account (FSA)
Group Life Insurance
Wellness Programs (when Medical care is provided)
Disability Benefits
Disease Specific coverages (IE. Critical Illness plans, etc.)
Virtual Medicine
Other
PAYMENT OPTIONS:
*
PayPal
Check
Products
Complete ERISA 'WRAP' DOCUMENT (Includes POP) $500
Premium Only Plan $250
Wrap 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
*
Submit
Should be Empty: