PHBP Employer Intake Form
The purpose of this form is for your company to make elections for the 2020 plan year on which plan bundles you will be offering to your employees, how you are going to contribute to the benefits for employees and dependents, and what those contributions are going to be. If you have contributions that are not standard, there will be a place at the end of the form to disclose what those are. Please use the PHBP Employer Expense Calculator to help analyze how much different contributions and bundles will cost.

If you have questions about anything on this form, please call Synergy Enrollment & Benefits at 858-322-6300 and ask for Garrett Smith
Legal Company Name *
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Company Contact Name: *
Whom should we contact if we have questions about this form?
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Company Contact Role/Position: *
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Company Contact Email: *
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Company Contact Phone Number: *
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What is the waiting period you have for new hires before they are eligible for benefits (e.g. the 1st of the month following 30 days)? *
Your answer
How often do you run payroll with benefit deductions? *
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