Submitted by:* |
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Email Address:* |
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Agency Info:
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Full Name:* |
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Agency: |
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Company Info:
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Company Name:* |
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Group Size:* |
(number of eligible employees) |
City:* |
(company headquarters) |
State:* |
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Zip Code:* |
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Number of locations:
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Effective date requested:* |
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Line of business:* |
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PacificSource group? |
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Special requests or more information:
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POP without full FSA:
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Please see our Premium Only Plan page.
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FSA Questions:
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(Premium contribution - "POP" portion - is included with FSA)
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Group currently has an FSA? |
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If so, number of participants: |
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Current plan year effective date: |
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Current TPA: |
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HRA Questions:
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Group currently has an HRA? |
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If so, number of participants: |
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Current plan year effective date: |
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Current TPA: |
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HRA Plan Design: |
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