SM•BCS
POP ORDER FORM
("Premium Only" Plan)

Please complete the information below to order the "Premium Only" package. The "package" will include the POP Plan Document, a Summary Plan Description brochure to reproduce and distribute to employees, and an employee enrollment (or declination) form. Please remit $150 to SMBCS (or an invoice will be enclosed when the package is sent).


PLAN INFORMATION

(Required Fields in Bold)
Employer (Plan Sponsor's) Name:
Street Address:
 
City:
State: Zip:
Phone Number:
 

Negative Enrollment Preferred
If checked all employees are to be automatically enrolled unless they
complete a form declining to participate. The form will be provided.

   
Subsidiaries:

Employer's Tax ID Number:

POP Effective Date:

,
Plan Year Begins:
 
Number of Employees:
Type of Health Coverage:
Fully Insured
Self-Funded
 
If we have questions which are not answered above, please
provide us with someone to contact for more information
Contact Name:
Contact's Email Address:
Phone Number:
Fax Number:

MAILING & BILLING INSTRUCTIONS
Mail POP Package to:
 
Street Address:
City:
State: Zip:
     

Send INVOICE to:

(Complete if different from the above)
Street Address:
City:
State: Zip:
Additional Comments:


Submit this form and someone will be in touch with you.
(You may wish to print this form before submitting.)

If you don't know some of the required information and would still like to submit
an incomplete form at this time, please press the button bellow.

Sharon Moe • Benefit Communication Services
21791 Lake Forest Dr. #206, Lake Forest, CA 92630
Phone: 949-380-9483, Fax: 949-586-0067
E-mail: sharon@erisacomply.com