Legal Name of Organization (Plan Sponsor) *Mailing Address *City *State/Province *ZIP / Postal Code *Employer's Federal Tax ID Number *0 / 10Entity Type *S-CorporationC-CorporationLLC or PLLCNonprofit Entity or ChurchPartnershipSole ProprietorshipOtherName of Employer Contact *Email Address of Employer Contact *Name of Broker / Advisor *Plan Administrator (Fiduciary), if different from EmployerRelated Employers Included in 125 Plan? *YesNoList Employer Name(s) and EIN(s) *Plan Renewal Date *Please select an optionSelect...January 1February 1March 1April 1May 1June 1July 1August 1September 1October 1November 1December 1Eligibility - Hours *30OtherOther Hours *Eligibility - Waiting Period *0 days30 days60 days90 daysOtherOther Waiting Period *Eligibility - Entry Date *Immediate (next day)First of Following MonthBenefits Eligible for Pre-Tax DeductionGroup Medical InsuranceGroup Dental InsuranceGroup Vision InsuranceHealth Savings Account ("HSA") bank account contributionsGroup Accident InsuranceGroup Critical Illness InsuranceGroup Hospital Indemnity InsuranceGroup Term Life Insurance (up to $50,000 coverage only)Group AD&D InsuranceGroup Short-Term Disability Insurance (special rules apply)Group Long-Term Disability Insurance (special rules apply)Group Telemedicine BenefitHealth Flexible Spending AccountDependent Care Spending AccountOtherOther Eligible Benefit(s) *Benefits Ineligible for Pre-Tax DeductionGroup Term Life InsuranceGroup Supplemental Life InsuranceGroup Short-Term Disability InsuranceGroup Long-Term Disability InsuranceOtherOther Ineligible Benefit(s) *Does the employer currently offer a Benefit Credit ("Flex Credit") or Waiver Credit? *YesNoBenefit Credit ("Flex Credit") or Waiver Credit *Payment OptionsPay Securely By Credit Card or Bank DraftI will mail a checkDiscount CodeSubtotal$Discount$Total$Make checks payable to:Simple 1251959 N. Peace Haven Road, #198Winston-Salem, NC 27106SubmitPlease do not fill in this field.