Form 5500 Data Collection

This form is designed to collect the information we need in order to prepare a Form 5500 submission. Please provide the following information:

Employer/Plan Sponsor Basic Information

Name of Employer*

Address of Employer*

City*

State*

ZIP*

Phone Number of Employer*

Tax ID / EIN*

Company Business Code*

6-digit code (view full list of codes)

Form 5500 Signer(s)

Please provide contact information for the individual(s) who will be electronically signing and submitting the Form 5500 once drafting is complete. Signers must register with Department of Labor's EFAST2 site.

Signer(s)*

First Name

Last Name

Email

Your Information

Your Name*

First Last

Your Email Address*

Your Phone Number*

You represent

an insurance broker agency

Broker Agency Name*

Data Contact Information

Will you be our data contact during this process?

The data contact is the individual who will receive the Form 5500 renewal email from Flores for future filing years. The Form 5500 renewal email requests employee participant counts and applicable Schedule As. The data contact can be some at the company or your broker contact. If you need to change your data contact in the future, please email us at 5500@probenefits.com.

Yes

No; someone else

Data Contact*

First Last

Email*

Invoicing Information

Will you be the invoice recipient?*

Once the Form 5500 process is complete, should we send the invoice for our services to you?

Yes

No; someone else

Primary Invoice Recipient*

First Last

Email*

Additional Invoice Recipients

Add another invoice recipient

Additional Invoice Recipient*

First Last

Email*

Insurance Broker Information

These fields are optional.

Broker Representative

First Last

Email

Broker Agency Name

Plan Details

In this Section, we ask that you (a) identify each health and welfare benefit program subject to ERISA that had 100 or more employees enrolled as of the beginning of the plan year and is sponsored or maintained by the Employer, and (b) furnish the corresponding details requested.

Examples of health and welfare programs include (but are not limited to): medical, dental, vision, basic life, supplemental life, dependent life, accidental death and dismemberment, short-term disability (unless it is a payroll practice), long-term disability, health reimbursement accounts (HRAs), employee assistance programs (EAPs) and flexible spending accounts (FSAs), as well as certain supplemental benefit programs, such as critical illness and hospital indemnity programs.

To begin, use the 'Add Plan' button below.

ERISA Plans to Include in this Form 5500 Filing

Plan Name (if known)	ERISA Plan Number	Plan Year Start	Actions

There are no Plans.

You're Almost Done!

Please review all responses for accuracy. If everything looks good, hit "Submit Application" at the bottom.

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By completing and submitting this Form 5500 data form, you acknowledge you have reviewed the Flores Form 5500 Preparation Service Memo of Understanding and agree to the terms and conditions set forth therein.