Distribution Email Form
Analyst Name
Please select...
fannie.fong@fmr.com
hannah.wisniewski@fmr.com
jennifer.ricciardello@fmr.com
michael.duchesneau@fmr.com
rebecca.mcbreen@fmr.com
scott.flaherty@fmr.com
stephanie.nick@fmr.com
danielle.mcallister@fmr.com
emily.lafountaine@fmr.com
elena.moseley@fmr.com
kimberly.mccausland@fmr.com
julie.finocchio@fmr.com
paul.onuska@fmr.com
al.rowland@fmr.com
eric.bither@fmr.com
lindsey.smith2@fmr.com
alyssa.burns@fmr.com
jason.kinsella@fmr.com
chiara.barnes@fmr.com
logan.woolums@fmr.com
erin.wheeler@fmr.com
jessica.delaney@fmr.com
lindsay.daum@fmr.com
Dominique.Dembo@fmr.com
Cortney.Stevenson@fmr.com
Sean.leahy@fmr.com
james.remmes@fmr.com
lily.hines@fmr.com
melissa.haley@fmr.com
nathan.piper@fmr.com
Segment/Document Type
Please select...
Large/Select/ECM/FIIS Agreement
Large/Select/ECM/FIIS Amendment
Strategic Agreement
Strategic Amendment
TEM Agreement
TEM Amendment
Executive Services
Consulting
Legal Client Name
Effective Date
Plan Numbers (or Client ID if non-DC):
Submitter's Email
Other's Email that should receive email
Service Lines (check all that apply)
DC
DC VS
DB
HW
HSA
HSA
VS
Non-Plan Specific Service
Consulting
VS
Reimbursement Accounts
Reimbursement Accounts
VS
Student Debt Retirement
Student Debt Retirement
VS
Standalone Consulting Services Agreement/Amendment
Student Debt Contribution Services
Student Debt Contribution Services
VS
Consulting as part of the MSA
Check all that apply:
Advisor Recurring Fee Deduction
Cash Dividend Pass Thru
Clean-up/Correction
Custom Funds
Data Privacy/Info Security
Executive Services
Fee changes
Fee for Service Rate Updates (Special Projects)
FMTC Commingled Pools
FPPA (fka PASW)
Fund Action
Includes Consulting Schedule with Liability Cap
Master Trust
MasterAdministrator or Outside Vendor Compliance Service
MIP/MIP2
NDT or 5500
New Plan Implementation (Agreement or Amendment)
Non-Standard Security Breach Provisions
Offshore Affiliate Restrictions
Offshore or On-Shore Subcontracting Restrictions
Other (explain in notes)
Performance Standards (SLA)
Public Sector Client
QDRO/Non-ERISA QDRO Service and/or Fee
RCP/PRC
Restatement (Agt Only)
SDB
Service Change
Stable Value
Plan Sponsor Non-Fiduciary
Consulting VS
PSW Single Sign-On
Enhanced Lost Participant Services (ELPS)
Auto Portability
ERISA 3(38) Investment Manager
Eligible Unenrolled Participant Disclosures - add or remove
Does this include Pre-Approved Volume Submitter?
Yes
No
Does this Fee change involved a change to billing frequency? i.e. monthly to quarterly
Yes
No
Advice Services (DOL)?
Yes
No
Which Advice Service?
MD please remember to submit a request to change the Participant Advice Indicator in Salesforce, if this is a change from Participant Advice
Participant Advice
Education
Education with Guidance
100% Non-ERISA (Not Applicable)
Participant Services?
in-Plan
Distribution
Which HSA?
Guided or Self-Service
Standard
Does this include HSA/FSRA SLAs?
Yes
No
403(b) VS Pricing Amendment?
Yes
No
Includes or Updates BAA?
Yes
No
Financial Wellness Included (Always at the Client Level)?
Yes
No
Which Financial Wellness Option Change Applies?
MD - CRITICAL STEP! Contact Middle Office to complete Financial Wellness set up via this link:
https://fidelityinvestments.tfaforms.net/660537
(Copy and Paste link into a browser)*
Please note this it not a required step for MDs when it is a new agreement.
ADDING FW Education Only
ADDING FW Education with Point Solutions
REMOVING FW Education Only
REMOVING FW Education with Point Solutions
CHANGING from FW Education Only to Education with Point Solutions
CHANGING from FW Education with Point Solutions to Education Only
MD - CRITICAL STEP! Contact Middle Office to complete Financial Wellness set up via this link:
Financial Wellness Setup Request - Form B
Adding/Removing Freedom Funds?
Yes
No
Freedom Fund Auto-Add Exception?
Yes
No
What is the Freedom Fund Auto-Add Exception?
Non-Plan Specific Services
Workplace Giving?
Yes
No
Payroll Deduction Services (Goal Booster)?
Yes
No
Student Debt?
Yes
No
Student Debt Match Calculations?
Yes
No
Student Debt Retirement?
Yes
No
Volume Submitter
?
Yes
No
Notes
Upload Fully Executed Agreement/Amendment(s)
Upload Agreement Summary Sheet
Contact Information