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Section 125 Premium Conversion (POP) Plans
Flexible Spending Accounts (FSAs)
Health Reimbursement Accounts (HRAs)

Premium Conversion Plan Subscription Form

Subscribing to BenefitsWorkshop's Premium Conversion Plan service is a two-part process.

1. Complete the form below and submit it to BenefitsWorkshop.
2. You will then be provided a choice of payment options.

There is a 30 day money back guarantee. If you are unhappy with the service for any reason, simply click on any "Contact Us" button and let us know that you want to cancel. Your money will be returned within six weeks of the date the notification was received.

Please enter the information below and press the "Submit to BenefitsWorkshop" The fields marked by an asterisk (*) are required!

*Name of Employer:

*Address:


*City:

*State:

*Zip Code:

*Number of Employees:

*Contact Name:

*Title:

*Phone:

*Fax:

*E-mail:

Coupon Code (if any):

Comments:




 

All BenefitsWorkshop services are provided by JAG Enterprises, LLC.