Request a Proposal | 121 Benefits

General Information

I am a(n): *

Employer Name *

Contact Name *

First Last

Email Address *

Phone

RFP Due Date *

Effective Due Date *

Include option for a Private Exchange in Defined Contribution *

Other Service(s) Description *

Please describe what other service or services you would like 121 Benefits to provide.

Number of Participants in ACA Reporting *

Number of Participants in Defined Contribution *

Total Benefit Eligible

Who currently administers these benefits for your organization?

Why are you requesting a proposal?

Please enter the number of current participants in each Pre-Tax account:

Number in FSA *

Number in Dependent Care FSA *

Number in HRA *

Number in HSA *

Number in Transportation *

Number in VEBA *

Number in Adoption Assistance *

Number of Qualifying Events in the last 12 months

Please enter the number of actives in each COBRA account:

Number in COBRA *

Number in Leave of Absence *

Number in State Continuation *

Number in Retiree Billing *

Number in Other Billing *

Additional Questionnaire (if applicable)

Accepted file types: PDF, DOC, DOCX (50MB limit)

Is there any additional information that would be helpful for us to know when preparing our proposal?

Comments

This field is for validation purposes and should be left unchanged.