Request a Quote | DBS Administration Services

Client Information

Client name*

Service(s) you are requesting a proposal (check all that apply)*

Flexible Spending Account (FSA)
Premium Only Plan (POP)
Health Reimbursement Arrangement (HRA)
Individual Coverage Health Reimbursement Arrangement (ICHRA)
Health Savings Account (HSA)
COBRA
Pre-tax Parking Plan (PPP)
ERISA Wrap Document

Is your client a current DBS customer?*

Yes
No

FSA information

Number of benefit eligible employees/members (FSA)*

is this a takeover of a current plan in place? (FSA)*

Yes
No

How many current participants are in the plan? (FSA)*

Why is your client seeking another third party administrator? (FSA)*

Effective date of the plan? (FSA)*

POP information

Number of benefit eligible employees/members (POP)*

is this a takeover of a current plan in place? (POP)*

Yes
No

How many current participants are in the plan? (POP)*

Why is your client seeking another third party administrator? (POP)*

Effective date of the plan? (POP)*

HRA information

Number of benefit eligible employees/members (HRA)*

is this a takeover of a current plan in place? (HRA)*

Yes
No

How many current participants are in the plan? (HRA)*

Why is your client seeking another third party administrator? (HRA)*

Effective date of the plan? (HRA)*

HSA information

Number of benefit eligible employees/members (HSA)*

is this a takeover of a current plan in place? (HSA)*

Yes
No

How many current participants are in the plan? (HSA)*

Why is your client seeking another third party administrator? (HSA)*

Effective date of the plan? (HSA)*

COBRA information

Number of benefit eligible employees/members (COBRA)*

is this a takeover of a current plan in place? (COBRA)*

Yes
No

How many current participants are in the plan? (COBRA)*

Why is your client seeking another third party administrator? (COBRA)*

Effective date of the plan? (COBRA)*

PPP information

Number of benefit eligible employees/members (PPP)*

is this a takeover of a current plan in place? (PPP)*

Yes
No

How many current participants are in the plan? (PPP)*

Why is your client seeking another third party administrator? (PPP)*

Effective date of the plan? (PPP)*

Should the proposal include or exclude commissions for your firm?*

Include
Exclude

Partner information

Your name (first and last)*

Title*

Firm name*

City/State*

Telephone*

Email*

Do you currently have clients doing business with DBS?*

Yes
No

How did you hear of DBS?*

Additional comments

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