Employers Contact Form

Required fields in RED

First Name:

Last Name:

E-mail Address:

Phone:

Fax:

Company/Employer:

Address 1:

Address 2:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip Code:

---

My company currently uses BeneFlex for plan administration:
Yes
No

My Company currently has employees eligible for a Pre-tax Benefit Plan.

My company currently has Pre-tax Benefit Plan(s):
Yes
No

What type of benefits are you interested in BeneFlex administering? (choose all that apply)
Health FSA
Dependent Care FSA
Mass Transit & Parking
Premium Only Plans (POP)
Cafeteria
HSA

My company currently utilizes transit checks:
Yes
No

I currently have a debit card program integrated with our company's plan:
Yes
No

I anticipate that my company will start our Pre-tax Benefit Plan:
Select Month January February March April May June July August September October November December Select Year 2004 2005 2006 2007 2008

The types of accounts that we are interested in including in our plan are: (choose all that apply)
Health FSA
Dependent Care FSA
Mass Transit & Parking
Premium Only Plans (POP)
Cafeteria
HSA

Comments/Questions: