Coordinator Assistance

Coordinator Assistance

Let's Get Started!
Your Name

First NameLast Name
Your Email Address*
example@example.com
Client Name*
# of Employees to See
Is this a new or existing account?

New AccountExisting Account: Open EnrollmentExisting Account: New Hires
Is there a broker on the account?

Yes - BrokerNo - Direct
Fast-Form Status (Currently)

Not SentSent, but not signedNeeds CorrectionsSigned/Complete
Broker/Producer Name

Coordinator Assistance

Client / Enrollment Basics (Page 2/5)
Billing Control # (BCN)
Commission Account # (CAN)
# of Remote Employees
# of Seasonal Employees
Employee List/Census Upload

Cancelof
New Hire Waiting Period
Eligibility Requirements
Coverage Effective Date

MonthDayYear
Date
Pay Periods

WeeklyBiweekly (Every other week)Semi-Monthly (Twice a month)Monthly
Premium Effective Date

MonthDayYear
Date
1st Deduction Date

MonthDayYear
Date
Enrollment Start Date

MonthDayYear
Date
Enrollment End Date

MonthDayYear
Date
Locations
Shifts

	Date	Time	Location	Attendees
Group Meeting
1x1 Follow-Up