Small Business Group Benefits Intake Form
Please complete this intake form for small business group benefits. All fields from the attached PDF should be included, and the form should use the provided logo.
Business Information
Business / Legal Name
*
DBA (if any)
Street Address
*
City
*
State
*
ZIP Code
*
Industry / Type of Business
*
Years in Business
*
Primary Contact and Workforce
Primary Contact Name
*
First Name
Middle Name
Last Name
Title
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Number of Full-Time Employees
*
Number of Part-Time Employees
*
Number of Employees Expected to Enroll
*
Current Coverage Details
Will coverage be offered to eligible dependents?
*
Yes
No
Undecided
Current health insurance carrier
Current plan type
Current monthly employer contribution
Current renewal date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current broker / agent (if any)
Requested Benefits and Contribution Preference
Desired Effective Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Benefits of Interest
*
Medical
Dental
Vision
Accident
Critical Illness
Life
Disability
Other
Other Benefits - Please Specify
Employer Contribution Preference
Additional Notes / Questions
Preferred Method of Contact
*
Phone
Email
Text
Authorization and Signature
Authorization
*
Yes
Authorized Representative Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: