Group Benefits Initial Intake Form
Agent Name
First Name
Last Name
Agent Email
example@example.com
Agent Phone
Please enter a valid phone number.
Group Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Federal Tax Identification Number (FEIN)
Group/Employer's Point of Contact (Other Than Writing Agent)
First Name
Last Name
Title
(HR Manager, Owner, etc.)
Phone Number
Please enter a valid phone number.
Email
example@example.com
Requested Effective Date
-
Month
-
Day
Year
Date
SIC Code (Standard Industry Code)
Group Size
Please Select
2-9 members
10+ members
Total Eligible Employees (not including spouse or dependents)
Please download:
Group Census
Under 10 Employees require a Personal Health Questionaire Packet
Personal Health Questionaire
Does the Group currently have a plan in place?
Yes
No
What type of plan?
Fully Insured
Level-Funded
Self-Funded
Employer Contribution
Percentage or Dollar Amount
Current Plan Documents
Fully Insured:
Current Rates
Renewal Rates (If Applicable)
Summary of Plan Description
Claims Reports (If Applicable)
Level-Funded:
Current Rates
Renewal Rates (If Applicable)
Summary of Plan Description
Claims Reports
High-Cost Claims Report
Self-Funded:
Current Rates
Renewal Rates (If Applicable)
Summary of Plan Description
Third-Party Administration (TPA) Contract
Stop-Loss Contract
Pharmacy Benefit Management (PBM) Contract
Claims Report
High-Cost Claims Report
Additional Documentation
Browse Files
Drag and drop files here
Choose a file
Such as Renewal documents or claims data.
Cancel
of
Timelines and Expectations
Once all data is submitted to Invictus, we will provide a timeline from the carriers on when they expect to release rates. If the data is missing information or is inaccurate the process will have to restart. It’s important to submit information that is accurate. If you have questions on the information we need to evaluate your group, please set up a call with Reece and Jordan.
Submit
Should be Empty: