GA, SD, WV
Multistate
PI-PLSP-BPSUPP 09/11 Page 1 of 2
COVER-PRO
SM
APPLICATION
BENEFIT PLAN CONSULTANT SUPPLEMENT
1. Full name of the Applicant Firm:
2. Please indicate the percentage of the Applicant’s gross annual revenue from the last
fiscal period involving:
A. Health and Welfare Plan Consulting
Single Employer Plans: %
Multiple Employer Benefit Plans (Taft-Hartley Trusts): %
Multiple Employer Welfare Arrangements (MEWA): %
Multiple Employer Trusts (MET’s): %
Health Maintenance Organizations (HMO’s): %
Preferred Provider Organization (PPO’s): %
Cafeteria Plans: %
Employee Assistance Programs: %
Group Life Insurance: %
AD&D: %
Dental Plans: %
Vision Plans: %
Section 125 Plans: %
Short and Long Term Disability Plans: %
Key Person Life Insurance: %
B. Defined Benefit Pension Plan Consulting:
%
C. Defined Contribution Plan Consulting
%
D. Profit Sharing Plan Consulting:
%
E.
Other (specify): %
TOTAL MUST EQUAL:
100%
3. Currently, or in the past five (5) years, has the Applicant Firm:
a. been involved in any financial consulting or planning? Yes No
b. been involved in any human resource consulting? Yes No
c. been involved in accounting and/or CPA’s services? Yes No
d. been involved in claims administration services? Yes No
e. been involved in insurance agent/broker services? Yes No
f. been involved in premium collection/billing services? Yes No
g. been involved in underwriting/policy issuance? Yes No
h. been involved in administrator for credentialing services? Yes No
i. been involved in electronic data processing/collection? Yes No
