Language
English (US)
Spanish (Latin America)
New Friend of The Revolution
(Intake Form)
Business Owner/Executive Name
*
First Name
Last Name
Business Owner/Executive Email
*
example@example.com
Main Contact Phone Number
Please enter a valid phone number.
Administrator Contact Name (Leave Blank if Same)
First Name
Last Name
Admin Email
example@example.com
Admin Phone Number
Please enter a valid phone number.
Company Name (Legal)
*
Physical Address
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Billing Address (If Different)
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
EIN
NAICS Code
# Employees
*
# Eligible
Number of Pay Periods
12
24
26
Est Eff Date
/
Month
/
Day
Year
Date
Please tell us a bit about your current plan options & the broker/advisor you are currently working with.
Do you already have ideas on what benefits programs you'd like to discuss?
Partially Self-Funded Plans
Direct/Virtual Primary Care
Medical Cost Sharing
Dental/Vision
Supplemental/Enhanced
Other
What are your goals with your benefits program?
Simplifying Benefits Administration/Integration
Improve Employee Engagement
Improve Employee Outreach
Reduce Costs/Make Costs More Predictable
Enhance Existing Benefits
Other
Anything Else You'd Like Us to Know?
Referring Advocate
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