SM•BCS
WRAP IT UP
ORDER FORM

USE THIS FORM TO ORDER A WRAP DOCUMENT/SPD.
When this form is completed, submit it and we will contact you to request any additional information that is needed.

TELL US ABOUT YOU
("You" are the Plan Sponsor / Employer / Client)
(Required Fields in Bold)

Company Name:
Contact:
Employer's Tax ID Number:
Street Address:
City:
State: Zip:
Phone Number:
Fax Number:
Email Address:
IF WE HAVE QUESTIONS ABOUT YOUR PLANS,
WHO (BESIDES YOU) MIGHT WE CONTACT?
Broker:
Account Manager:
Office:
Street Address:
City:
State: Zip:
Phone Number:
Fax Number:
Email Address:
DO YOU NEED A "FOREIGN LANGUAGE OFFER OF ASSISTANCE"?

If you have a certain number of Plan participants who are not literate in English, you may need to offer to help them in understanding your Plan(s). Please complete the following:

If you have less than 100 participants, are 25% or more only literate in the same
non-English language? Yes, No

If you have more than 100 participants, are 10% or 500 or more (whichever is less)
only literate in the same non-English language? Yes, No

If "yes" to either question, in which language(s) do they write & speak?

PLEASE PROVIDE US WITH MAILING & BILLING INSTRUCTIONS
Mail
WRAP Document/SPD to:
Broker, Client
Mail Invoice to:
Broker, Client
     
Additional Comments:


You may submit this form to SMBCS and someone will contact you to discuss what other pieces of information will be needed to begin the preparation of the Wrap SPD. To expedite handling, however, you may want to print the Word or PDF versions of the complete (3-part) Wrap Order Form and instructions.
Upon completion, you can fax them to 1-949-586-0067.

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