Intake Form
"
*
" indicates required fields
This intake form will help us produce your Enrollment Meeting on Demand™ and build your company Benefit Hub™.
Here’s the information you’ll need handy.
Client, Broker and Contact Detail’s
Upload File of All Benefit Summaries, SBC’s and Plan Documents
A2P Registration Details
Basic Info
Company Name
*
Company Website Link
*
Company Contact
*
Business Email
*
Street Address
*
City
State
Country
Postal code
Do you have any Spanish speaking employees
Yes
No
Client Details Cont.
HR Contact
*
HR Email
HR Phone
Signatory Name
*
Signatory Email
*
Broker Agency Detail
Broker Agency Name
*
Broker Web Address
*
Broker Contact
*
Broker Support Contact
*
Broker Support Phone
*
Broker Support Email
*
What enrollment platform are you using currently?
*
Broker logo
Drop files here or
Select files
Max. file size: 100 MB.
Eligibility & Structure
Please list your benefit eligible classes. If more than one, do they have access to differing benefit programs?
*
Waiting Period
Date of Hire
First of the Month
First of the Month Following 30 Days
First of the Month Following 60 Days
The Day Following 90 Days of Employment
Is coverage available to spouses or dependents?
Yes / No
Yes
No
Benefit Plan Detail
Please upload your zip file for all the active benefits you wish to have covered in your Enrollment Meeting on Demand™ or linked to your Benefit Hub for employee access. Include all benefit summaries, SBC's, plan documents, and your current benefits guide. You can upload one by one, but a zip file upload is easiest.
Click to upload files here
*
Drop files here or
Select files
Max. file size: 100 MB.
Compliance and Company Document Upload
Please upload any additional non-benefit related documents that you would like housed on your Benefit Hub and made available to employees. Include any compliance or company policy documents here.
Click to upload files, or drag & drop files here
Drop files here or
Select files
Max. file size: 100 MB.
Capturing the Highlights and Important Focal Points
You know your group best! When we're producing your Enrollment Meeting on Demand, it's helpful to note if there is anything you wish to pay a bit more attention to, highlight, celebrate, spend more time on, or specifically market to employees. It's important we know. Do you have any specific plan funding details, contributions, plan enhancements, or other aspects you wish to highlight or focus on? Are there any benefits offered that are new or experiencing significant changes this renewal period?
Please be as detailed as possible with this information:
*
Important Contacts:
Please upload all contact information that should be provided to employees during the Enrollment Meeting on Demand. This includes carrier contacts, web URLs, email addresses, phone numbers, and any other contacts that employees may need to utilize.
Contact Sheet
Drop files here or
Select files
Max. file size: 100 MB.
Can you please provide your health carrier's network provider search link?
Poster Style
Now that we have your benefit plan details, it's time to select your poster style to direct employees to their benefit hub at open enrollment and year round.
Poster Style
Benefits That Rock
Healthcare
Touchdown
Hot Rod
Rock Climber
American Athlete
Open Road
Surfs Up
Benefits That Soar
Benefits To Love
Rocket Ship
Reach New Heights
Family
Clarity
Fighter Jet
SMS Carrier Compliance
Note: The information below is required to apply for A2P compliance regarding SMS messaging to employees for open enrollment communications.
Company EIN
*
Business Type
*
Co-operative
Corporation
Limited Liability Company or Sole Proprietorship
Non Profit Corporation
Partnership
Mobile Number (for registration purposes when applying for A2P this number will receive a confirmation text message to confirm the setup, there will not be any further communications via this number and it is for setup only)
*
CAPTCHA
Principal Rep Name
Principal Rep's Email
Principal Rep's Phone
Advisor's Agency Name
Advisor First Name
Advisor Last Name
Advisor Mobile
Advisor Email
Client Information
Company Name
Street Address
City
State
Country
Postal code
Company Website
Renewal Date
Company EIN
The EIN is required for A2P SMS compliance to verify the business entity applying for the plan.
Client Contact
Client's Contact First Name
Client's Contact Last Name
Program Types
Dental Insurance
Pet Insurance
Accident Insurance
Disability Insurance
Vision Insurance
Critical Illness
Hospital Indemnity
Life Insurance
Client's Contact Email
Client's Contact Mobile
This number is required for registration purposes and will only be used once during the A2P SMS compliance process. The contact may need to provide a validation code during registration.
Upload Principal Plan and Summaries
Notes
Submit
