PCORI Fee Reporting Services for New BPC Clients

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. Orders after July 7th are considered rush orders and cost $300.

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

First Name

Last Name

Company

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

FEIN

Tax Filing Status

C-Corp

S-Corp

Partnership

Sole Proprietor

Non-Profit

LLC

Other

Plan Offerings

Check all that Apply

Health Reimbursement Account

Self-Insured Health Plan

Plan Year End Date

YYYY

Additional Comments

Participant count on the last day of the 1st quarter.

For Health Reimbursement Accounts, participant counts only include participating employees. Dependents are excluded from HRA count.

Participant count on the last day of the 2nd quarter.

For Health Reimbursement Accounts, participant counts only include participating employees. Dependents are excluded from HRA count.

Participant count on the last day of the 3rd quarter.

For Health Reimbursement Accounts, participant counts only include participating employees. Dependents are excluded from HRA count.

Participant count on the last day of the 4th quarter.

For Health Reimbursement Accounts, participant counts only include participating employees. Dependents are excluded from HRA count.

Terms and Conditions

By placing my initials below, I acknowledge that I have read and accept the Provider Service Agreement for PCORI Fee Reporting and Compliance.