ERISA Compliance Evaluation Form OCA Request for ERISA Compliance Services This application is for evaluation and proposal purposes only. Once this application is submitted, OCA's ERISA compliance and Sales team will provide a full review of its discovery with the requested parties identified on this form. Please Select Requested Services (select all that apply): * Wrap Document Form 5500 Filing Other option Do you have 100 or more enrolled employees? * Yes No You indicated that you have 100 or more enrolled employees. Please indicate the approximate year in which you reach 100 enrolled. / Month / Day Year Back Next Employer Information Plan Sponsor (Employer ) Full Name * Federal Tax-ID * List Any Affiliated Company (IES) & EIN(S) Employer Address * Street Address Street Address Line 2 City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Primary Contact Name * First Name Last Name Primary Contact E-mail * Primary Phone Number Broker Contact * First Name Last Name Broker E-mail * Broker Phone Number Benefits Please complete each question so that our compliance team can properly review your request for services. Please select all benefits offered: * Medical Dental Vision Term Life Insurance Supplemental Life Insurance Dependent Life Insurance Short Term Disability Long Term Disability HRA Health FSA Limited Purpose FSA Dependent Care FSA Other option Please provide the appox # of employees * Plan Year Period * / Month / Day Year Back Next Thank you for your interest! Once this form is submitted, OCA and it's ERISA compliance partners will provide a full ERISA compliance evaluation. Once completed, we'll be reaching out to review what the next steps will be. Thank you again for the opportunity to be of service! Name of individual submitting application * First Name Last Name Who should be the point of contact? * Broker Contact Only Employer Contact Only Both OCA Sales Representative * Brian McCauley Jason Davey John Crotty Ross Honig Steve Honig Unknown Submit Print Form Should be Empty:
