ScriptSourcing Work Order

AccountID
BenefitsApp Lead Form
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 the Client pursuant to BenefitsApp's Terms & Conditions.
ScriptSourcing Contact
Your name, or the ScriptSourcing Contact for this lead.
Today's Date

MonthDayYear
Work Order submission date.
Employer Group or Client Name
The company that will use BenefitsApp for their employees
Client/Broker Point of Contact:

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
BenefitsApp Lead Form:

Please refer to BenefitsApp.com/ScriptSourcing/ for details on Client Order Levels.
Client Order Level:

Level 1 provided by ScriptSourcingLevel 2 ($1,000)Level 3 ($3,000 Set up fee $0.50 PEPM)Reseller or Custom Level (to be quoted)
Target Launch Date :

MonthDayYear
The launch date is the target date for release to employees.
Estimated Number of Users: (records per census file)
Employee, Employee + Spouse and/or Dependents to be included on the eligibility census file.
Other instructions:
Please provide instructions for billing and any other comments related to the client's BenefitsApp.
If available, please upload the most recent Benefits Guide and additional files for the BenefitsApp.

DO NOT UPLOAD CENSUS DATA HERE.
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BenefitsApp Lead Form