POP Application

Admin America Section 125 Premium Conversion Plan Application

"*" indicates required fields

1EMPLOYER INFORMATION

2PLAN INFORMATION

3AFFILIATES

4AUTHORIZED COMPANY CONTACT INFORMATION

5AGENT BROKER INFORMATION

6BILLING INFORMATION

Applicant Name

First Last

Applicant Email

EMPLOYER INFORMATION

Employer/Plan Sponsor Full Legal Name*

Enter the Full Legal Name as it appears on the articles of incorporation or tax return, including punctuation and capitalization.

Employer/Plan Sponsor Tax ID Number*

The Employer Identification Number, also known as the Federal Employer Identification Number or the Federal Tax Identification Number, is a unique nine-digit number assigned by the Internal Revenue Service to business entities operating in the United States for the purposes of identification.

Employer/Plan Sponsor Entity Type

Owners (Members, Partners, etc.) of Entity Types other than Corporations are not eligible for participation in the Plans maintained by that entity. More than 2% shareholders of S-Corporations and their family members are not eligible for participation in Plans maintained by the S-Corporation.

Employer/Plan Sponsor Organization State

State

Total # of Employees*

Employer/Plan Sponsor Street Address*

Street Address

Employer/Plan Sponsor City*

City

Employer/Plan SponsorState*

State

Employer/Plan Sponsor Zip Code*

ZIP Code

Employer/Plan Sponsor Phone Number

Enter the Employer/Plan Sponsor Waiting Period as Number of Days*

What is the Entry Date After the Waiting Period is Over?*

Does the Employer/Plan Sponsor offer a pre-taxed Health Savings Account?*

BILLING INFORMATION & SUBMISSION

Section 125 POP

Price:

Coupon

Total

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Contact*

First Last

Billing Contact Email*

Enter Email Confirm Email

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Phone

Admin America Section 125 Premium Conversion Plan Application

EMPLOYER INFORMATION

PLAN INFORMATION

AFFILIATES

COMPANY CONTACT INFORMATION

AGENT/BROKER INFORMATION

BILLING INFORMATION & SUBMISSION