Sales Handoff Form
VBA Sales Lead
Company Name
*
Company URL
Primary Implementation Contact Name
*
First Name
Last Name
Primary Implementation Contact Title
*
Primary Implementation Contact Email Address
*
Primary Implementation Contact Email Address
example@example.com
Summary of why the client purchased our solution
*
Is this a New or Existing Client?
*
New Client
Existing Client
What lines of business does this client offer?
*
Benefit Payment
Captive
Care Management
Consultants
Dental Insurance
Fully Insured
Government (including MA/Medicaid)
Health Sharing Program
Integrated Health Insurance Network (IHIN)
Life Insurance
Long Term Insurance
MEWA
PBM
Self Funded Insurance
Short Term Insurance
Supplemental Insurance
TPA
Vision Insurance
Please list any additional project team members below
Rows
Additional Contact 1
Additional Contact 2
Additional Contact 3
Additional Contact 4
Additional Contact 5
Name
Email Address
Title
Phone Number
Please Provide Billing Contact Information Below
Rows
Primary Contact Information
Secondary Contact Information
Billing Contact Name
Billing Contact Email
Biling Contact Title
Go-Live Date Details
*
Client will work with VBA on a mutually agreed go-live date
Client requested specific go-live date
Client's Requested Go-Live Date
/
Month
/
Day
Year
Date
Contract Terms
*
1 Year
3 Years
5 Years
Are there any interfaces or reports included in the client's contract
*
Yes
No
How many interfaces or reports are included in the contract
What is the pricing for any additional interfaces or reports not included in the contract
Please list details regarding custom reports and interfaces included in the client's contract (Interface Vendor Names or High level Custom Report Information)
Provide additional details on any unique/non-standard contract terms
Any additional information or comments related to implementation, contract details, or go-live dates
Please select the solutions the client purchased
Attach copy of Rate Sheet, Statement of Work and/or Addendum Here
Browse Files
Cancel
of
VBASoftware
Purchased
Number of concurrent users
*
Number of concurrent users
VBAGateway
Purchased
Please select the portals purchased by the client
Member
Provider
Broker
Employer
Open Enrollment
Did the client include VBAMobile?
Purchased
VBAMobile (only for existing clients with VBAGateway)
Purchased
VBA TotalEnrollment
Purchased
VBA TotalEnrollment includes the following:
VBASoftware (Adjudication engine not turned on)
VBAGateway
Member Portal
Employer Portal
VBASoftware (Premium Billing - requires groups, enrollments, plans, rates)
VBAGateway (Member Online Enrollment Portal)
VBAGateway (Employer Portal)
VBAVoice - IVR
Purchased
What types of calls and transactions will IVR be used for?
VBAVoice - Chat
Purchased
What portals will Chat be deployed on?
Member
Provider
Broker
Employer
Enrollment
VBANotifications
Purchased
VBAPI
Purchased
VBAnalytics
Purchased
Number of Additional VBAnalytics Licenses Purchased (10 Licenses are included )
What Analytics Package and Options Were Purchased
Base
Plus
Premium
Value Base Care Reporting
HRA Assessment Reporting
Advanced VBA Reporting
Purchased
Submit
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