CBIZ M T Doanhoe And Associates

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 PDonahoe@cbiz.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

Prospect Information
Company Name:
Contact: Phone: Email:
# of Eligible Employees:     # EEs on health:     # EEs on dental:
Current FSA or COBRA Activity
Plan renewal date:  How administered: 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: 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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