Link Benefits New Business Intake Form

New Business Intake Form

- PLEASE REVIEW -

Note for agents: You will need information from your company contact to complete this form. It is encouraged to gather the required documents, then review this form with the client to complete in the most efficient fashion.

You can save this form at any point and return to it at any time. There is a "save" button at the bottom of each page that records your progress. You will receive an email with a link to return to the saved form at a later time. A quick guide on how to save and send to your client can be found HERE

For Priority Health Business:

A list of required, but commonly missed items to successfully fill this form is available HERE

Please note this list is not exhaustive

Additional documents for signature: Depending on products sold, additional documents for signature may be generated to fufill carrier requirements. If you are selling Priority Health, keep an eye out as there will be at least one additional document requiring signature once this form has been completed.

These documents are circulated electronically and will be sent directly to your and/or your client's email. There will be an email for each document requiring a signature.

For ancillary coverage placements: We will follow the carrier's preferred onboarding process. The information provided in this form will be delivered to the appropriate onbarding teams upon completion.

For benefit administration system builds: If requesting a benefit administration build out or revision, there will be a second form sent when this submission is received and reviewed. This form will only request information not provided below and will prefill many datapoints already gathered in this form. The agent will receive a separate prompt via email to complete the build form.
Agent & Agency Information
Agent Name*

First NameLast Name
Agency Name*
Agent/Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Agent Email*
example@example.com
Agent Phone*
Please enter a valid phone number.

Company Information

Please note: If you'd like to move on to the next page without a required answer, you may enter a placeholder. Just remember to come back and enter the true value, once determined!
Company Legal Name*
Company Structure*
Is this Company under Common Control with another Company?*

YesNo
Is this a PEO or Leasing Company?*

YesNo
Company Address*

Street Address

Street Address Line 2

CityState

Zip Code
Separate Billing Address?

Yes
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
Company TIN*
Total Number of Employees*
Includes all employees; full-time, part-time, seasonal, and variable hour employees
Number of Full-time / Full-time Equivalent Employees*
Determine the number of Full-time Equivalent Employees (FTEs) and enter that number here.
Number of Eligible Employees*
Effective Date of Coverage*

MonthDayYear
Date
Current Date

MonthDayYear
Date
Lead Time

Group Contact Information

Please note: If you'd like to move on to the next page without a required answer, you may enter a placeholder. Just remember to come back and enter the true value, once determined!
Admin Contact Name*

First NameLast Name
Admin Contact Email*
Admin Contact Phone Number*
Please enter a valid phone number.
Billing Contact Name*

First NameLast Name
Billing Contact Email*
Billing Contact Phone Number*
Please enter a valid phone number.
President / CEO Full Name*

First NameLast Name

Priority Health

Fully Funded Small Group New Business
2-50 ACA Medical Plan Selections
Sold Plan #1*
Examples: POS 1000, POS HSA 2500 100%, HMO 2500, Southeast MI Partners HMO 1000
Sold Plan #2
Examples: POS 1000, POS HSA 2500 100%, HMO 2500, Southeast MI Partners HMO 1000
Sold Plan #3
Examples: POS 1000, POS HSA 2500 100%, HMO 2500, Southeast MI Partners HMO 1000
Sold Plan #4
Examples: POS 1000, POS HSA 2500 100%, HMO 2500, Southeast MI Partners HMO 1000

Priority Health

Fully Funded Small Group New Business
Additional Coverage Information
Has {companyLegal} ever had coverage with Priority Health*

YesNo
Previous group number*
Name of most recent medical insurance carrier*
Workers’ compensation carrier*
Workers’ compensation policy number*
Are you offering early retiree coverage?*

YesNo

Priority Health

Fully Funded Small Group New Business
Administration Solutions
If offering HRA, is Priority Health administering the HRA? Note: 30-day lead time for HRA products.*

YesNo
If offering HSA, would you like to use HealthEquity as the banking partner for the HSA plan?*

YesNo
Would you like to use HealthEquity to administer FSA?*

YesNo
Is your company required to offer COBRA?*

YesNo

Priority Health

Fully Funded Small Group New Business
Documentation & Attestation
PLEASE NOTE: PLACEHOLDER DOCUMENTS NOT ACCEPTED! Please revisit this form at a later date if you do not have all required documents. You can save your progress by clicking the save button at the bottom of the page and return via the emailed link once all required information is obtained.
Upload W9*

Cancelof
Upload UIA 1028*

Indicate on the UIA 1028 form if an employee is terminated, part-time or otherwise ineligible for coverage
Cancelof
Are there any owners enrolling that do not appear on the UIA 1028?*

YesNo
OPTIONAL: Upload Voided Check (if ACH auto-pay is desired)

Cancelof
Sole Proprietor: Upload Schedule C & Copy of Federal Tax ID Verification*

Cancelof
Partnership: Upload Schedule 1120 & Articles of Incorporation or federal doc w/ FEID*

Cancelof
Corporation: Upload Schedule 1120 & Articles of Incorporation or federal doc w/ FEID*

Cancelof
Farmer: Upload Schedule F*

Cancelof
Limited Liability Company: Upload Schedule 1065 & Articles of Organization*

Cancelof
Nonprofit: Upload IRS Verification Form and state licenseor certification and copy of applicable tax filing for entity*

Cancelof
Based on today’s date, did you have 20 or more employees for 20 or more calendar weeks during the previous or current calendar year? Note: Includes full-time, part-time, intermittent, leased and/or seasonal employees excluding self-employed individuals.*

Yes — If you met this threshold during the previous year or current calendar year, please provide the date that this threshold was reachedNo — Please enter today’s date
Date*

MonthDayYear
Date
Did you have 100 or more employees during 50 percent of your business days during the previous calendar year? Note: Includes full-time, part-time, intermittent, leased and/or seasonal employees excluding self-employed individuals.*

Yes — Enter 1/1 of the previous calendar year dateNo — Please enter today’s date
Date*

MonthDayYear
Date
Small groups who are not purchasing coverage on the Health Insurance Marketplace must purchase pediatric dental benefits as part of Essential Health Benefits under health care reform. Even if you don’t have children under the age of 19, you’re required to purchase pediatric dental.*

Yes — I already have purchased pediatric dental coverage through a certified stand-alone dental carrier.No — I do not currently have pediatric dental coverage, but understand this is a requirement and certify my intent to purchase this
Signature* (Agent of record signature is acceptable)
Authorized Signer Name*
Agent of record is acceptable
Authorized Signer Title*
Agent of record is acceptable
Signature Date*

MonthDayYear
Date

Census File Upload
Enrollment Census for Direct Submission to Carrier
- Employee first & last name
- Employee status (active, leave, etc.)
- Employee email address (important if using benadmin)
- Employee phone
- Gender
- Birth date
- Hire date
- Employment class (if applicable)
- Job title
- Annual salary -or- hourly wage
- Scheduled hours
- SSN
- Home address
  - Street address
  - City
  - State
  - Zip code
- Dependent names, genders, and birth dates
- Dependent relationships (spouse, domestic partner, child, etc.)
- Election for each member (enrolled or waived) for each plan
  - Election tier for dental, vision, accident etc.
  - Name of elected plan (if multiple options)
  - Volumes for voluntary benefits (vol. life, critical illness, vol. disability,etc.)
  - Benefit class (if applicable)
- Effective date of coverage
The Priority Health enrollment census template can be downloaded HERE.
Direct Submission Census Upload*

Cancelof
If you would rather submit the census to the Link team later, please check the box below:

Census will be emailed at a later date

Paper Form Enrollment
Upload Employee Enrollment Forms Below*

Please note that for employees that are not enrolling and are otherwise eligible for benefits, please indicate a waiver reason on the UIA 1028 form. Waiver forms are also permitted.
Cancelof
If you would rather submit the forms to the Link team later, please check the box below:

Forms will be emailed at a later date

Submit Application
Please add any additional details not previously requested in the intake form
Should be Empty:

Agent & Agency Information

Company Information

Group Contact Information

Carrier & Plan Selection

Eligibility Provisions

2-50 ACA Medical Plan Selections

Additional Coverage Information

Administration Solutions

Documentation & Attestation

Census File Upload

Paper Form Enrollment

Submit Application