Group Client Information Form

Group Client Information Form
Thank you for inquiring about group benefits for your company. At 843BHM, we aim to educate you on your options and create a strategic, sustainable plan that grows with your business. We strive to be a trusted resource and a key part of your success!

To get started, we need to gather some data. The more details you provide, the more specific our guidance can be, so please be as thorough as possible!
Company Name
Principal Contact Name
Principal Contact Email
example@example.com
Principal Contact Phone
Please enter a valid phone number.
Company FEIN
SIC Code (if known)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Renewal Date or Target Coverage Effective Date

MonthDayYear
Date
For starters, tell us a little about your company, and what your goals are for a benefits plan?
What is your current contribution plan for all benefits?
If new to benefits, what is your budget per Employee?
Do you wish to offer different contributions for different classes of employees?
Would you like to offer different contributions for different employee classes?
Waiting Period for New Hires (Typically 1st after XX days)
Are you using online benefit administration software?
List provider if known
Are you currently working with another agency?
List agency if known
Current Medical Provider:
Current Supplemental Provider(s)
List all if applicable
Current Payroll Vendor:
Pay Cycle Frequency
Do you need to integrate ACA Reporting?
Do you need bills broken up by divisions or locations?
Please select the benefits you would be interested in for your employees?

MedicalDentalVisionGroup LifeVoluntary LifeShort Term DisabilityLong Term DisabilityAccident CoverageGAP InsuranceCancer ProtectionPet InsuranceFSAHSA401(k)Other
Is there anything else you would like to share about your goals for a benefits plan?
Please upload your most recent bills, benefit summaries, or renewal documents here. We prioritize the confidentiality of these documents and assure you that they will not be shared with any third parties without your explicit consent.

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In order to run quotes we need a complete census of all full time eligible employees. Please download our census document HERE that has already been formatted to work with many of our carrier partners.

Please note that providing income data is a critical step in determining if your coverage is deemed "affordable" and if your employees might be eligible for federally subsidized plans at a reduced cost.

For more information please visit us at www.843benefits.com.
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