Wrap SPD Application - ProBenefits

A Wrap SPD document is used to consolidate or “wrap together” (into a single document) various ERISA-governed benefit programs sponsored by the Employer. The form below is designed to collect the information we need in order to prepare a Wrap SPD for the benefit programs, as consolidated (the "Consolidated Plan"). Please provide the following information:

Employer/Plan Sponsor Basic Information

Name of the Employer*

Address of the Employer*

City*

State*

ZIP*

Employer/Plan Sponsor Basic Information

Phone Number of the Employer*

Ext.

Tax ID / EIN*

Approximate # of Employees*

Plan Administrator

Will the Employer/Plan Sponsor serve as the Plan Administrator of the Consolidated Plan (i.e., the ERISA fiduciary with authority to interpret the Wrap SPD document and make decisions on behalf of the Employer)?*

Yes

No

If the Employer has designated a specific person, title-holder, or entity (such as John Doe, the Director of Human Resources, or the ABC Benefit Plan Committee, respectively) to serve as the Plan Administrator, please identify the following:

Name or Title of Person or Entity*

Same Address as the Employer?*

Yes

No

Address of Person/Entity*

City*

State*

ZIP*

Same Phone as the Employer?*

Yes

No

Phone Num. of Person/Entity*

Ext.

Agent for Service of Process

Will the Employer serve as the Agent for Service of Process (i.e., the person or entity to receive notice if a lawsuit or similar action is filed against the Consolidated Plan)?*

Yes

No

If the Employer has designated a specific person, title-holder, or entity (such as John Doe, the Director of Human Resources, or the ABC Benefit Plan Committee, respectively) to serve as the Agent for Service of Process, please identify the following:

Name or Title of Person or Entity*

Same Address as the Employer?*

Yes

No

Address of Person/Entity*

City*

State*

ZIP*

Same Phone as the Employer?*

Yes

No

Phone Num. of Person/Entity*

Ext.

Affiliated Entities

An entity is a related or affiliated entity if such entity and the Employer are under common ownership, part of the same controlled group of corporations, or are trades or businesses under common control. If you are uncertain as to whether an entity meets the applicable parameters, please consult your legal counsel.

Are there any related or affiliated entities with employees who participate in any of the benefit programs that will be included in the Consolidated Plan?*

Yes

No

Participating Affiliates

Name

Tax ID / EIN

Individual Requesting Document Preparation

Your Name*

First Last

Your Company*

Employer Named Above

Other (please specify)

Company Name*

Your Email Address*

Your Phone Number*

Ext.

Document Delivery

The prepared document will be delivered electronically. Should it be delivered to you?*

Yes

No

Should the email communication containing the prepared document and additional guidance on its use and distribution be addressed to you?*

Yes

No, I prefer to be copied on the communication

Please identify below the individual(s) to whom the prepared document should be delivered.

Please identify below any individual(s) to be copied on the communication. (optional)

Please identify below the individual(s) to whom the communication should be addressed.

Individuals

First Name

Last Name

Email

Invoice for Services

At the completion of the project, Flores will send an invoice and collect payment for the project. Should the invoice be sent to you?*

Yes

No

Primary Invoice Recipient*

First Last

Email*

Additional Invoice Recipients

Add another invoice recipient

Additional Invoice Recipient*

First Last

Email*

Wrap Plan Information

The Wrap SPD document will also serve as the Consolidated Plan document. Please provide the following information regarding the Consolidated Plan:

Does the Employer currently have a Wrap SPD and/or Consolidated Plan document in place with respect to its benefit programs?*

Yes

No

What was the effective date of the most recent Wrap SPD and/or Consolidated Plan document?*

What name was given to the Consolidated Plan in the most recent Wrap SPD and/or Consolidated Plan document?*

Please upload a copy of the most recent Wrap SPD and/or Consolidated Plan document here, if available.

Accepted file types: pdf, doc, docx, Max. file size: 64 MB.

Wrap Plan Information

The Wrap SPD document will also serve as the Consolidated Plan document. Please provide the following information regarding the Consolidated Plan:

Official Name selected for the Consolidated Plan*

Examples: "The ABC Company Health and Welfare Plan" or "The XYZ, Inc. Consolidated Benefits Plan"

3-Digit Plan Number for the Consolidated Plan*

Note: Health and welfare plans are numbered consecutively starting with 501. Generally, once a plan number is used for a particular plan/program, it should always be used in connection with that plan/program and should not be used for any other plan/program, even if the first plan/program to use the number is later terminated.

Please enter a number from 501 to 599.

Plan Year*

Please identify the start date of the 12-month record-keeping period selected for the Consolidated Plan (i.e., the “Plan Year”), which may vary from the plan year/policy period/period of coverage that applies to one or more of the benefit programs included in the Wrap SPD document.

Has the Employer established a Trust or Trust Fund for purposes of paying for any of the benefits provided under the Consolidated Plan?*

Yes

No

Please provide the formal name given to the Trust*

Which benefit programs are funded by the Trust?*

All of the benefit programs included in the Consolidated Plan

All of the self-funded benefit programs included in the Consolidated Plan

Only certain benefit programs (please specify):

Specify Benefit Programs Included*

Benefit Program Details

In this Section, we ask that you (a) identify each health and welfare benefit program subject to ERISA that 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) arrangements providing one or more of the following benefits: medical, dental, vision, basic life, supplemental life, dependent life, accidental death and dismemberment, short-term disability, long-term disability, flexible spending accounts (FSAs), health reimbursement accounts (HRAs), and employee assistance programs (EAPs); as well as certain arrangements providing one or more “supplemental” benefits, such as critical illness or hospital indemnity coverage.

To begin, use the 'Add Benefit Program' button below.

Benefit Programs

Type	Name	Actions

There are no Benefit Programs.

Supplemental Benefit Programs

If the previous list includes any supplemental benefit programs, please identify those supplemental program(s), if any, that pay for or reimburse medical expenses.

For example, a cancer policy may pay for or reimburse certain treatment costs, such as chemotherapy and/or other medications (i.e., medical expenses). Alternatively, the policy may pay a fixed amount upon the occurrence of a particular event (i.e., an indemnity policy), whereby the amount of the payment is not related to that individual’s medical expenses and is not coordinated with the individual’s other coverage.

Additional Details

Are there any additional details that are unique to the Consolidated Plan or other important information that should be addressed in Wrap SPD document?

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 Wrap SPD data form, you acknowledge you have reviewed the Flores Wrap SPD Preparation Service Memo of Understanding and agree to the terms and conditions set forth therein.