Form 5500 Questionnaire

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In order for Benecon to begin preparing your Form 5500, please complete the information below. Also, please review all prepopulated information and update it accordingly if it is incorrect. 

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Employer Information







If Business Code is unknown please provide your industry.


Additional Contact(s)



Plan Information
Please enter your plan information below. If you noted that you have two plans there is a an additional section for the second plan.








Total Number of Participants
Employees & former employees who are covered by the plan; does not include spouses or dependents.



If Benecon administers your COBRA you don't need to provide this information.

Note: This is the method for the receipt, holding, investment and transmittal of plan assets prior to the time the plan actually provides benefits

Note: This is the method by which the plan provides benefits to the participants.
List any service provider who rendered services to the plan and received $5,000 or more in compensation, directly or indirectly, from the plan and the amount received.
Example: TPA, Actuary, Accountant, Consultant, or HRA, HSA, FSA Administrator


Benefits offered under the group health plan
Please list ALL benefits offered under this plan below. Please include all coverage types including medical, dental, vision, HRA/MERP, group term life, short term disability, long term disability, supplemental insurance, etc.  





























Secondary Plan Information
Please enter your plan information below for your secondary plan.








Total Number of Participants
Employees & former employees who are covered by the plan; does not include spouses or dependents.



If Benecon administers your COBRA you don't need to provide this information.

Note: This is the method for the receipt, holding, investment and transmittal of plan assets prior to the time the plan actually provides benefits

Note: This is the method by which the plan provides benefits to the participants.
List any service provider who rendered services to the plan and received $5,000 or more in compensation, directly or indirectly, from the plan and the amount received.
Example: TPA, Actuary, Accountant, Consultant, or HRA, HSA, FSA Administrator


Benefits offered under the group health plan
Please list ALL benefits offered under this plan below. Please include all coverage types including medical, dental, vision, HRA/MERP, group term life, short term disability, long term disability, supplemental insurance, etc.  











Please identify the total amount received in employee contributions/COBRA premiums for medical premiums during the plan year. The figures should come from the groups payroll records/COBRA administrator. 

Don't use $ or commas. If no employee contributions, please enter 0.00.

Do not use $ or commas. If no COBRA contributions, please enter 0.00. If Benecon administers your COBRA you don't need to provide this amount.

Auditor Information







This email address will receive a copy of the submission.


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Contact Information