Request a ProposalEmployersService OfferingsCase StudiesRequest a ProposalVideo DemosLet us show you how you and your employees can benefit from fusing our depth of experience with the highest level of service. General InformationI am a(n): * RequiredSelectBroker working on behalf of an employerEmployer seeking a vendor for my own companyEmployer Name * RequiredContact Name * Required First Last Email Address * Required PhoneRFP Due Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Effective Due Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Service NeedsWhich Administrative Services would you like 121 Benefits to propose? * Required FSA Dependent Care FSA HSA HRA VEBA Transportation Adoption Assistance COBRA Leave of Absence State Continuation Retiree Billing Other Billing ACA Reporting Defined Contribution Wellness Account Other ServiceInclude option for a Private Exchange in Defined Contribution * Required Yes NoOther Service(s) Description * RequiredPlease describe what other service or services you would like 121 Benefits to provide.Number of Participants in ACA Reporting * RequiredNumber of Participants in Defined Contribution * RequiredTotal Benefit EligibleWho currently administers these benefits for your organization?Why are you requesting a proposal?Pre-TaxPlease enter the number of current participants in each Pre-Tax account:Number in FSA * RequiredNumber in Dependent Care FSA * RequiredNumber in HRA * RequiredNumber in HSA * RequiredNumber in Transportation * RequiredNumber in VEBA * RequiredNumber in Adoption Assistance * RequiredCOBRANumber of Qualifying Events in the last 12 monthsPlease enter the number of actives in each COBRA account:Number in COBRA * RequiredNumber in Leave of Absence * RequiredNumber in State Continuation * RequiredNumber in Retiree Billing * RequiredNumber in Other Billing * RequiredAdditional InformationAdditional Questionnaire (if applicable)Accepted file types: PDF, DOC, DOCX (50MB limit)Accepted file types: pdf, doc, docx, Max. file size: 50 MB.Maximum file size - 50 mega bytes. Is there any additional information that would be helpful for us to know when preparing our proposal?CommentsThis field is for validation purposes and should be left unchanged.