Consulting or White Label Inquiry Intake

Welcome to Aevitas! To better understand your needs and preferences, please complete this brief intake form. Whether you're interested in our consulting services or exploring white-labeling opportunities, your input is crucial. We'll gather essential information about your organization, goals, and expectations. Questions will cover your current benefits structure, challenges, and desired outcomes. This form serves as the foundation for tailoring our services to meet your unique requirements. Let's embark on this journey together, ensuring a seamless and customized experience with Aevitas.

Name

First NameLast Name

E-mail

example@example.com

Phone

Company

Role at Company

Ex. Consultant, Advisor, etc

Are you interested in:

What is the time frame for the need for services?

Where is group domiciled?

State where the group is domiciled:

Are you (or do you have clients) interested or needing support with: (select all that apply)

Active Employee Medicare SupportAging Workforce Benefit ConsultationAging Workforce Compliance SupportDefined Retiree Benefit Options & SustainabilityEmployee Retirement Planning SupportMSP Questionnaire Support and ComplianceOff-Boarding and COBRA Mitigation SupportSelf-Funded Medicare Claims AuditOther

What are you trying to accomplish with Aevitas services?

Please describe the groups current benefit plan: (if applicable)

How did you hear about us?

Social MediaWord of MouthAdvertisementOther

Please define "Other"

Consulting Services or White Labeling Needs: