Non Discrimination Testing Quote Request Please fill out the following information below. Note: All fields are required except for EIN. Company Name Company Contact Name Contact Phone Contact Email Employer Identification Number Please check all applicable health and welfare plans your company sponsors: Section 125 PlanHealth Savings Account (HSA)Dependent Care FSAHealth FSASelf-Insured HealthHealth Reimbursement Arrangement (HRA)Employer Provided Group Term Life Are you part of a controlled group? YesNo Brokerage Firm Brokerage Contact Name Brokerage Contact Email
