Vantage Flex, LLC HOME FORMS FSA/HRA STORE HIPAA/PII SECURITY SERVICES CONTACT US MY ACCOUNT Install a POP Plan To install a plan, please complete the following form. Once you have submitted it to our office, you will be contacted to verify your order. Company Name EIN Address City State Zip Contact Name Phone Number Email Address Fax Principal Office Location (State) Start Date End Date Effective Date Organization Type Corporation S Corporation Limited Liability Company Professional Corporation Partnership Government Entity Non-Profit Organization Class of Eligible Employee Same as Group Health Plan All Employees Salaried Employees Hourly Employees Service Period Requirements 90 Days after hire 60 Days after hire 30 Days after hire Date of Hire Other Entry Date Date Requirements are met First pay period following requirements First day of the month following requirements Benefits Coordinator Core Health Insurance Company Name Non-Core Health Insurance Benefits Group Term Life Insurance Disability Insurance Dental Insurance Cancer Insurance Vision Insurance AD&D Insurance Prescription Drug Coverage Other Insurance Coverage Group Term Life Insurance Company Name Is the employer subject to FMLA Yes No Is an HSA provided by the employer Yes No Notes Agent Name Agent Phone Number Quoted Annual Fee Quoted Monthly Fee Site Mailing List The Future of Employee Benefit Administration Vantage Flex, LLC 413 10th Avenue Menominee, MI 49858 Phone: (906) 863-3539 Email: bill@vantageflex.com

Vantage Flex, LLC HOME FORMS FSA/HRA STORE HIPAA/PII SECURITY SERVICES CONTACT US MY ACCOUNT Install a Self Funded Dental Plan If you have questions, or would like more information, please leave your name and contact information. First Name: Last Name: Email Address: Address: City: State: Zip Code: Comments: Site Mailing List The Future of Employee Benefit Administration Vantage Flex, LLC 413 10th Avenue Menominee, MI 49858 Phone: (906) 863-3539 Email: bill@vantageflex.com

Vantage Flex, LLC HOME FORMS FSA/HRA STORE HIPAA/PII SECURITY SERVICES CONTACT US MY ACCOUNT Install Vision Plan If you have questions, or would like more information, please leave your name and contact information. First Name: Last Name: Email Address: Address: City: State: Zip Code: Comments: Site Mailing List The Future of Employee Benefit Administration Vantage Flex, LLC 413 10th Avenue Menominee, MI 49858 Phone: (906) 863-3539 Email: bill@vantageflex.com