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 *

Which Administrative Services would you like 121 Benefits to propose? *

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)

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

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

Name

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