PCORI Fee Reporting Services for New BPC Clients

Thank you for your interest in BPC's PCORI Fee Reporting Services. Please complete the form below and a BPC Benefit Specialist will contact you to complete your report. 

Upon completion of your report, you will be invoiced in the amount of $150.00. Please read the Provider Service Agreement for PCORI Fee Reporting and Compliance. You will be asked to confirm your acceptance below.

*Required field

Contact Name *
Contact Name
Address *
Address
Phone *
Phone
Tax Filing Status *
Plan Offerings *
Check all that Apply
Plan Year End Date *
Plan Year End Date
Participants counts only include participating employees. Dependents are excluded from count.
Participants counts only include participating employees. Dependents are excluded from count.
Participants counts only include participating employees. Dependents are excluded from count.
Participants counts only include participating employees. Dependents are excluded from count.
By placing my initials below, I acknowledge that I have read and accept the Provider Service Agreement for PCORI Fee Reporting and Compliance.

Please read the Provider Service Agreement for PCORI Fee Reporting and Compliance.