Simple 5500 Data Form – Simple Benefits Compliance

This form is intended to collect basic company and plan information to help our team prepare a Form 5500 for your organization. After you submit the form, a member of our compliance team will review the info as well as any current or past Form 5500 filings in the DOL’s database. Then, we will contact the listed individual (company contact or agency representative) to obtain the remaining info needed.

This data form includes an electronic payment option for the annual fee ($350). If you prefer to pay by check, you may select “I Will Mail A Check” rather than payment by card or bank draft, and we will send an invoice by email.

Thank you for contacting Simple 5500. We look forward to serving you.

Legal Name of Company (Plan Sponsor) *

Mailing Address *

City *

State/Province *

ZIP / Postal Code *

Employer's Federal Tax ID Number *0 / 10

Name of Contact for Plan Data *

Email Address of Contact *

Plan Fiduciary or Individual Signer of 5500

ERISA Plan Year Basis *

Payment OptionsPay Securely By Credit Card or Bank DraftI will mail a check

Discount Code

Subtotal

$

Discount

$

Total

$

Make checks payable to:

Simple 125
1959 N. Peace Haven Road, #198
Winston-Salem, NC 27106