American Benefit Services

American Benefit Services Proposal Request

Agent Name

Agent Phone Number

Agent E-mail

Name of Group

Group Address

Address (cont.)

Group City

Group State/Province

Group Zip/Postal Code

Country

Type of Industry

Business Entity Type

Sole Proprietor	C Corp	LLC	Not-for-profit
Partnership	S Corp	Church	Government

Number of Employees

Are all employees at one location?

Yes

If not, please list all locations including city, state and zip code

What type of plan are you interested in?

POP

FSA

HRA

HSA

CORBA

SSB
Single Source Billing

Is this a new plan or an amendment to an existing plan?

New

Existing

Benefits under this plan will include:
(required for POP or FSA)

Medical Expenses

Dependent Care Expenses

Health Premiums

Dental Premiums

Other Premiums

If Other Premiums, please specify

Any other questions or comments that will help process your request?

If you have any questions regarding this form, please contact us.

If you prefer, you can print out a copy of this form to fax or mail in using the link below

American Benefit Services

Mailing Address:
Post Office Box 1635
Irmo, SC 29063

Phone / Fax Numbers:
803-407-0133
866-826-6554 (toll-free)
803-749-3621(fax)

Email:
info@abstpa.com