BenefitsApp Work Order

AccountID
BenefitsApp Work Order
This Work Order when submitted (the “Work Order”) is made and entered into effective today (“Today's Date”), by and between BenefitsApp Inc. (“BenefitsApp”) and you (“Client”) pursuant to BenefitsApp's Terms & Conditions.
Today's Date

MonthDayYear
Work Order submission date.
Employer Group or Client Name
The company that will use BenefitsApp for their employees
Your Contact

First NameLast Name
Your Company Name and Location
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Client Point of Contact:

First NameLast Name
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.
The term of this Work Order shall be twelve (12) months from the Launch Date (the “Initial Term”), and shall thereafter automatically renew for successive one (1) year terms (each, a “Renewal Term”) unless either party gives written notice to the other party at least ninety (90) calendar days prior to the expiration of the then-current term of its intent not to renew the Work Order.

The Client may receive a copy of this work order and/or a Non-Disclosure Agreement (NDA) for their approval by signature prior to starting production.
Send Client Contact

Send Work Order and NDASend NDA onlyDo not send
BenefitsApp Order Form:

For Annual License and PMPM, Contact sales@benefitsapp.com or enter "request quote" in the fields below.
BenefitsApp Annual License:
If a rate has been quoted, this will be their annual invoiced amount invoiced upon signed agreement.
BenefitsApp Per PMPM:
Per Member Per Month rate quoted to Client and will be their annual, quarterly or monthly invoice for total number of users (e.g. total number of unique member IDs able to register and use BenefitsApp on their mobile phones)
Invoice PEPM*

Annually based on actual number of census member IDs (employees) on the launch date. Reviewed yearly on renewal. (Invoiced upon signed agreement)Monthly (Invoiced by 3rd day of each month)Annual Fee no PMPM
Target Launch Date :

MonthDayYear
The launch date is the target date for release to employees.
Org Code:
Unique code for user registration. The Company code is a short form of the company name, for example "xcorp" for X Corporation or IBM for International Business Machines. BenefitsApp will confirm or assign the Org Code with the Client Contact
Census File to be provided?

YesNoUnsure
Estimated Number of Classes: (variations of benefit offerings, e.g. FT vs PT)
Does the employer group have one or more benefit guides? One for full-time vs part-time. Or variations among groups of employees?
Estimated Number of Users: (records per census file)
Employee, Employee + Spouse and/or Dependents to be included on the eligibility census file.
Expected Standard Administrators:
Number of Standard Administrators with access to employee personal information, self-service SMS and Push messaging features. No access to self-service reports. Reports are per request of BenefitsApp. One Standard Administrator is included with each license.
BenefitsApp Licensee: (receives invoices)*

You or BrokerClient
Accounts Payable Email:
If known, AP Email address for responsible party to receive a BenefitsApp invoice.
Invoice or Other Instructions:
Please provide instructions for billing and any other comments related to the client's BenefitsApp.
Additional Production and Messaging Fees:
- Creative Production Management by BenefitsApp: $75/hour (push message development, marketing literature or other) for pre-approved creative production management.
- SMS Fees: 10 messages per member per month included, $0.01 per message after 10 messages.
- Push/In-App Fees: 10 messages per member per month included, $0.01 per message after 10 messages.
If available, please upload the most recent Benefits Guide and additional files for the BenefitsApp.

DO NOT UPLOAD CENSUS DATA HERE.
Cancelof
Please verify that you are human*
By submitting this signed Work Order, the BenefitsApp team will review the BenefitsApp specification, and if everything is in order, BenefitsApp will send a Client Agreement with NDA for digital signature to your Client Contact's email.

Upon signature, BenefitsApp will send an Annual Invoice (Annual License + Annual PEPM if that option is checked) to the Accounts Payable Email address. Upon payment, the BenefitsApp team will engage the Client Contact for development and distribution of BenefitsApp to their employee members.
Should be Empty:

BenefitsApp Work Order

BenefitsApp Order Form: