Wrap SPD Application Form

A wrap plan and a wrap summary plan description (SPD) may be used to consolidate (or “wrap together”), into a single document, various ERISA-governed health and welfare benefit programs sponsored by an employer. The term “ERISA” refers to the Employee Retirement Income Security Act of 1974, as amended. ERISA is a federal law that applies to most employer-sponsored health and welfare plans (as described in more detail below).

[Note: Although ERISA also applies to employer-sponsored retirement and pension plans, such plans are not intended to be included in wrap plan documents.]

This Application Form is designed to collect the information Flores needs to prepare a Wrap SPD that consolidates the various ERISA-governed health and welfare benefit programs sponsored by the Employer identified below. The Wrap SPD document prepared by Flores is also intended to serve as the Employer’s Wrap Plan document. Please review all questions and instructions carefully. If your responses are inaccurate or incomplete, you will be responsible for any editing required upon receipt of the document.

Click 'Next' to begin the application.

Employer/Plan Sponsor -- Basic Information

Name of the Employer that will sponsor the Wrap Plan*

Address of the Employer*

City*

State*

ZIP*

Employer/Plan Sponsor -- Basic Info

Phone Number of the Employer*

Ext.

Tax ID / EIN of the Employer*

Approximate # of Employees*

Plan Administrator

Will the Employer/Plan Sponsor serve as the Plan Administrator of the Wrap 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 (e.g., John Doe), title-holder (e.g., the Director of Human Resources), or entity (e.g., the ABC Benefit Plan Committee) 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 Number 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 designated to receive notice of any lawsuit or similar action that is filed against the Wrap Plan)?*

Yes

No

If the Employer has designated a specific person (e.g., John Doe), title-holder (e.g., the Director of Human Resources), or entity (e.g., the ABC Benefit Plan Committee) 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 Number as the Employer?*

Yes

No

Phone Num. of Person/Entity*

Ext.

Affiliated Entities

The Employer/Plan Sponsor may permit employees of a related entity to participate in the Employer's benefit plans, if the related entity satisfies certain tax affiliation rules. An entity is a related or affiliated entity if such entity and the Employer are under common ownership, are 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.

Does the Employer offer any benefit programs to the employees of its related or affiliated entities (if any)?*

Yes

No

Not applicable

Participating Affiliates (4 maximum)*

Name

Tax ID / EIN

Individual Requesting Document Preparation

Your Name*

First Last

Your Company*

Employer named previously

Other (please specify)

Company Name*

Your Email Address*

Your Phone Number*

Ext.

After Flores has received your completed Application Form, Flores will prepare the Wrap SPD and will deliver it to you electronically for your review.

Additional Recipients (3 maximum)

Specify additional recipients

Additional Recipients (3 maximum)*

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

Invoice Recipient*

First Last

Email*

Wrap Plan Information

Please provide the following information regarding the Employer's Wrap Plan status:

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

Yes

No

What was the effective date of the Employer's most recent Wrap SPD and/or Wrap Plan?*

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

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

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

Wrap Plan Information

As stated above, the Wrap SPD document prepared by Flores will also serve as the Wrap Plan document. Please provide the following information for the Employer’s Wrap Plan:

Official Name of the Wrap Plan*

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

3-Digit Plan Number assigned to the Wrap 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 Wrap 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 Plan.

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

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

Only certain benefit programs (please specify):

Specify Benefit Programs Included*

Benefit Program Details

Generally, an ERISA-governed health and welfare program is any plan, fund or program established or maintained by an employer for its employees and their beneficiaries, to the extent such plan, fund or program is established or maintained for the purpose of providing the following (through the purchase of insurance or otherwise):

medical, surgical, or hospital care or benefits;
benefits in the event of sickness, accident, disability or death; or
prepaid legal services.

Examples of ERISA-governed health and welfare programs include (but are not limited to) arrangements that provide one or more of the following benefits:

basic life
supplemental life
short-term disability
long-term disability
business travel accident (BTA)
prepaid legal services
“supplemental” benefits (e.g., critical illness, hospital indemnity, specified disease, accident coverage)

medical
dental
vision
health flexible spending accounts (FSAs)
health reimbursement accounts (HRAs)
employee assistance programs (EAPs)
accidental death and dismemberment (AD&D)

In this Section, please (a) identify each ERISA-governed health and welfare benefit program sponsored or maintained by the Employer, and (b) furnish the corresponding details requested. If you are uncertain as to whether the Employer or any benefit offered by the Employer is subject to ERISA, please consult with appropriate benefits counsel.

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

Benefit Programs

Type	Name	Actions

There are no Benefit Programs.

Additional Details

Are there any additional details that are unique to the Employer's benefit programs or other important information relating to a particular benefit program that should be addressed in the Wrap SPD?

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.