New Account Quote/Set Up Form for Worksite Benefits

New Account Quote/Set Up Form for Worksite Benefits
If you have questions filling this form out please contact Ricky DeFalco 405-200-5361 or email ricky@enhancedbenefitsok.com

This form is not specific to a carrier. All information will only be used for quoting and account activation with chosen carriers.

Account activation will require a decision maker signature or conference call with chosen carrier.
Legal Company Name*
Date the company was formed

MonthDayYear
Date
DBA name (if applicable)
Employer Identification Number (EIN)*
Legal Entity Type*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different than physical address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Primary Contact *

First NameLast Name
Primary Contact Title*
Email (primary contact)*
example@example.com
Phone Number (primary contact)*

Area CodePhone Number
Secondary Company Contact Person (optional)

First NameLast Name
Secondary Contact Title (optional)
Secondary Email (optional)
example@example.com
Secondary Phone Number (optional)

Area CodePhone Number
Number of Benefit Eligible Employees*
Are Domestic partners allowed to enroll in the plans?*

NoYes, opposite sex partners onlyYes, opposite sex and same sex are allowed
New Employee wait period*
Employee Paycycle*
Plan Start Date*

MonthDayYear
Pre-Tax plan Start date (if different than plan start date)

MonthDayYear
Date
First Payroll Deduction Date*

MonthDayYear
This date will be the first payroll cycle after the plan start.
Second Payroll Deduction Date*

MonthDayYear
Do we need to create/provide a free Section 125 (POP Plan)?*

YesNoI don't know
Company Website (Optional)
Business Type/Description (SIC Code if available)*
Will benefits be offered through a benefit platform? (if yes, please give details/platform name in the Notes section below)*

NoYesMaybe
Notes regarding account enrollment platform
Will account require onsite enrollments in multiple locations? (if yes, please list location cities/states below)*

NoYesMaybe
Locations that will need onsite enrollments
General Notes (please include any account information that you feel may be important)
If you are requesting quotes for Basic Life, Vol Life, STD, LTD or taking over another carrier's product(s), we will require an employee census. The employee census should include; date of birth, gender, job description or title, salary and date of hire.

If we are quoting a carrier change please include current benefit summaries and the most recent invoices.
Should be Empty: