Link Benefits Proposal Request Intake Form

Group Information
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company Contact Email
OPTIONAL: for use at time of sale
Company TIN
OPTIONAL: for use at time of sale
Company SIC Code
Required for MetLife quotes
Company Size*
Priority Health quote page available for ACA (2-50) market space only
Effective Date*

MonthDayYear
14 day lead time for coverage submission is required, must be on the first
Desired Proposal Due Date*

MonthDayYear
Standard delivery timeframe is 10 business days. Timeframes can vary by time of year
Is this group new or existing business for Link Benefits?*

New BusinessExisting Business

Census Upload Section
Census Information 2-50 Medical Only

Please upload a census that contains all information required to quote all lines of coverage selected. Please download one of the following templates if needed. Once opened in your browser, click file>download to manipulate a copy.
- 2-50 census template
- 51+ census template
For medical only coverage, the following infromation is REQUIRED for each member:
1. First Name
2. Last Name (EE, SP, CH)
3. Relationship
4. Date of Birth
5. Enrollment Status
For ancillary only coverage, the following infromation is REQUIRED for each eligible employee:
1. First Name
2. Last Name
3. Date of Birth
4. Dental Enrollment
5. Dental Plan
6. Vision Enrollment
7. Vision Plan
8. Enrollment amounts for vol. life/disability options
9. Zip Code
10. Hire Date
11. Job Title
12. Job Class
13. Compensation
Upload Census Here*

PLEASE NOTE: Do not submit more than the requested demographic information, specifically items like SSNs. This form submission is secure, but data distribution to vendor partners may expose unnecessary PII if uploaded to this form.
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Proposal Request Form