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CBIZ HCM Administration – Request for Proposal
Complete this online form and hit Submit.
If you print this form, please send completed form to Patrick Donahoe at
Patrick.Donahoe@Amwins.com
You will be contacted within 48hrs. Thank you.
Questions: 1-800-231-1559
Check the box(es) for the administrative services you would like to see
FSA Plan Administration
Premium Only Plan
COBRA Administration
Prospect Information
Company Name:
Address:
Contact:
Phone:
Email:
# of Eligible Employees:
# EEs on health:
# EEs on dental:
Business/Industry:
C Corp.
S Corp.
Partnership
Sole Proprietor
Non-Profit
Current FSA or COBRA Activity
Plan renewal date:
How administered:
In House
or Outsourced to:
Participant Information
# of EEs in medical accounts:
# of EEs in dependent care accounts:
Does your plan offer the 2-½ month grace period?
Payroll provider:
In House
or Outsourced to:
Payroll Frequency:
For COBRA, # of current COBRA continuants:
Average # of monthly "Qualifying Events":
Broker or consultant please complete this section
Name:
Company:
Phone:
Email:
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