Insta-Quote Form

Please select lines of services you're interested in:

Plan Documents

POP Document

Wrap Document

Continuation Coverage

COBRA Administration

How many benefits-eligible employees are there?

Direct & Retiree Billing

How many billing participants are there?

Benefits Administration

Medical Flexible Spending Account / Dependent Care Assistance Program

How many employees will participate in the Medical FSA And/or DCAP benefits?

Health Reimbursement Arrangement

How will the plan issue reimbursements?

The participant can begin receiving reimbursements immediately (1st Dollar)

The participant must meet a deductible before receiving reimbursements (2nd Dollar)

ICHRA

QSEHRA

HSA

LSA

Transit Reimbursement Account

How many employees will participate in the selected benefits, that are not ALSO in the FSA?

How should reimbursements be handled?

The group will use reports to handle reimbursements in-house. (employer handles reimbursements to participants)

The group will use automated direct deposit reimbursements. (Bank handles reimbursements to participants for the employer)

Would you like a Benefit-Linked Debit Card?

Yes

IRS & DOL Compliance

Form 5500 Filing

How many years of filings need to be completed?

ACA Reporting

IRS Penalty Letter

What type of penalty letter did you receive?

5699

226J

Unknown

What is the amount of the penalty?

Who are you preparing this Quote for?

My Business

My Client

Broker Name

Broker Company Name

Broker Email Address

Broker Phone Number

Name of Client for the Quote

Anticipated Effective Date

Comments

Company Name

Contact Name

Contact Email Address

Contact Phone Number

Anticipated Effective Date

Comments

Additional Email Addresses to Copy (comma-separated)

Would you like to insert the company logo into the quote page?

Drag the image to this Drop Zone ...

Broker ID or Promo Code

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Hello ,

Thank you for requesting a quote from Diversified Administration, Inc. We have received your submission, and will prepare a proposal offering a comprehensive and competitive solution for your client, .

We look forward to the opportunity to work with you, and help find the best benefits compliance solutions for your client.

Thank you for considering Diversified Administration, Inc.

Hello ,

Thank you for requesting a quote from Diversified Administration, Inc. We have received your submission and will prepare a proposal offering a comprehensive and competitive solution for .

We look forward to the opportunity to work with you, and help find the best benefits compliance solution, tailored to your needs.

Thank you for considering Diversified Administration, Inc.