EXISTING Client Data Intake Form - Rework or New Hire Enrollment

  • EXISTING Client - New Hire OR Open Enrollment

    This form is for existing accounts that have a new hire, open enrollment, or other enrollment event needed. Provide as much information and detail as possible. The more information you provide the better we can serve you and the group.
  • Is this a New Hire event or an Open Enrollment event?*

  • Please allow a minimum of 72 business hours ONCE ALL DATA HAS BEEN RECEIVED for processing open enrollment events.

    Existing groups moving to a new platform require at least one week's notice (Once all data received) for processing.

  • Changes to Opener Required?
  • Opener Commission Split Required?
  • Rows
  • Broker Influence
  • New Hire Eligibility
  • Will we provide the group's Section 125 through AmeriFlex?

  • Enrollment Details

    Please provide as much information as you can - anything the BC may need to know about the group including personality of the PA, employee demographics, etc.
  • Open Enrollment Type - did we previously enroll core? will that remain?

  • Is this a Passive or Active Core Enrollment? i.e. are employees required to complete an enrollment or will all coverage roll over with no employee action.
  • Do we need to send an Open Enrollment email from Nav/Gathr?
  • Have you confirmed that the employee census is up to date in the enrollment platform?
  • What other benefits does group offer?

  • Are we making any changes to the Colonial products*
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  • Do you want our team to create a Digital Postcard for the group? Card will be sent to Sales Contact / Opener unless otherwise specified.
  • Has an enrollment date been scheduled & confirmed with the account?*

  • Expected Enrollment Start Date
     - -
  • Expected Enrollment End Date (MINIMUM 5 days prior to CED)
     - -
  • COVERAGE EFFECTIVE DATE*
     - -
  • Enrollment Working Conditions*

  • BC SELECTION EXPECTATIONS

    In person enrollments - please schedule your benefits counselor directly and select them below once confirmed. If you need assistance in booking a BC for an on site enrollment contact your territory enrollment team.

    Virtual Enrollments - please select your BC preference(s) or "no preference". BCs will be booked based on availability, licensing, and fit for the group. Your preference may not be available. Multiple BCs may be assigned to virtual enrollments.

    Agents are expected to book employee appointments for virtual appointments, or work with the group to ensure appointments are booked by EEs. BCs are not required or expected to call and book employee appointments.

    If you ask for us to book a benefit counselor we will do our best to schedule your preferenced selection but make no guarantee of their availability.

  • If you have a preference for BC, please select them here. If no preference, a BC will be assigned based on availability. If IN PERSON enrollment, please schedule your BC directly.*

  • Employer Contribution?*
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  • Which Complimentary Benefits do you want to offer?*
  • POP offer qualified for Year 2? Requires 10+ eligible EEs and met participation requirements previous enrollment.
  • Calendly Schedule Link Required?*

  • Is Call Center enrollment only required? i.e. are there employees who don't have access to a computer for screen sharing?

  • Product Details

    Select Product & Options and any changes needed for enrollment event.
  • Are we making changes to the product offering for this enrollment?

  • Short Term Disability (State specific)*
  • Benefit Periods (will be set up based on state/product restrictions)
  • Depending on benefit periods, first day hospital and mental/nervous disorders will be elected unless unchecked. State requirements may dictate selection.
  • Accident - IA 4000*
  • Critical Illness 1.0*
  • Cancer Assist*
  • Individual Medical Bridge (Hospital Plan)*
  • Plan Level Offering (State specific setup will apply)
  • Select desired hospital level. Only 2 allowed and cannot be more than $1,000 apart. $4k & $5k require UW approval.
  • Additional IMB Settings (State specific requirements will apply)
  • Dental - PPO*
  • Offering the PPO 8000 or PPO 8100?*
  • Dental 8000 Plan Offering (2 max)
  • Include in Dental PPO 8000 Plan Design:
  • Dental 8100 Plan Offering (2 Max)*
  • Include Vision Rider
  • Include 8100 Orthodontia Rider*
  • Dental Fee Schedule*
  • Term Life 5000*
  • Whole Life 5000+*
  • New Offering Group Plans?*

  • Should be Empty: