Benefit Administration System Set Up Form

Benefit Administration System Set Up Form

The information provided will be used to choose the benefit system and to build the case. For questions please contact Ricky DeFalco at 405.200.5361 or Ricky@enhancedbenefitsok.com
If you begin filling this form out and need to stop, make sure to use the save feature at the bottom. This will create a hyperlink that is sent to your email. That hyperlink will allow you to continue the form at a later date.
Today's Date

MonthDayYear
Date
Brokerage Name
Company/Account Name*
Date the Company was formed

MonthDayYear
Date
Company logo upload (optional)

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Does this employer have any divisions or locations that receive different plans or contributions?

YesNo
Please explain the divisions/locations details
Enrollment Start Date*

MonthDayYear
Enrollment End Date*

MonthDayYear
Plan Effective Date*

MonthDayYear
Is this enrollment system being set up primarily for employee self enroll?

YesNo
Please check the products being offered to the employees.*

MedicalDentalVisionShort-Term DisabilityLong-Term DisabilityAccidentHospitalCritical IllnessBasic LifeGroup Voluntary LifeLegalIdentity ProtectionFSA Medical/Dependent Day CareTelemedicineOther
Please check the products that will be offered on a pre-tax basis.*

MedicalDentalVisionShort-Term DisabilityLong-Term DisabilityAccidentHospitalCritical IllnessBasic LifeGroup Voluntary LifeLegalIdentity ProtectionFSA Medical/Dependent Day CareTelemedicineOther
Are the plans subject to Cobra?

YesNo
Who is the TPA for Cobra?
Cobra Contact information, if applicable
Name, Mailing Address, Phone and Email
Please list the plans that are subject to Cobra, if applicable
Employee Qualification Info
New Hire Wait Period
# of weekly work hours to qualify for benefits?
Please list ineligible employees/divisions/locations.
What are the age limits for children (is it different for ft students)?
Do they recognize common law marriage?

YesNo
Do they recognize same sex common law marriage?

YesNo
Medical Plan Information
Please explain the employer/employee contribution design of the medical insurance and any other notes.
Medical Age Determination
This will determine cost at enrollment and calculations for attained age products moving forward.
Upload plan Medical Plan documents here (SBC(s) and any other important docs)

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Dental Plan Information
Please explain the employer/employee contribution design of the Dental insurance and any other notes.
Upload plan Dental Plan documents here

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Vision Plan Information
Please explain the employer/employee contribution design of the Vision insurance and any other notes.
Upload plan Vision Plan documents here

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Short-Term Disability Plan Information
Please explain the employer/employee contribution design of the STD insurance and any other notes.
STD Age Determination?

Issue AgeAttained Age
STD Age Determination if using attained age
This will determine cost at enrollment and calculations for attained age products moving forward.
Upload plan STD Plan documents here

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Long-Term Disability Plan Information
Please explain the employer/employee contribution design of the LTD insurance and any other notes.
LTD Age Determination
This will determine cost at enrollment and calculations for attained age products moving forward.
Upload plan LTD Plan documents here

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Basic Life Plan Information
Please explain the employer/employee contribution design of the Basic Life insurance and any other notes.
Upload plan Basic Life Plan documents here

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Voluntary Life Plan Information
Voluntary Life Age Determination
This will determine cost at enrollment and calculations for attained age products moving forward.
Please explain the employer/employee contribution design of the Voluntary Life insurance and any other notes.
Upload plan Voluntary Life Plan Plan documents here

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Other Contributions
Please explain any other company contributions being made.
Other Documents for the Benefit Admin System
What other information or documents will be uploaded in the system.
Upload any documents that the employer would like the employees to have or review here

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Who is the producer/account manager that will be available for set up questions?
List anytime team member that is assisting with the account or account setup. Name/Email/Phone
Primary Broker/Agent contact*

First NameLast Name
Broker/Agent Phone Number*

Area CodePhone Number
Broker/Agent Email*
example@example.com
Please send a copy of each plan benefit summary and employee benefit guide for upload in the system. A current copy of the annual notices should be included for placement. Copies of the carrier quotes help when building the system.

We need a copy of any other questions, videos, links or documents that will be set up in the system.

Please send documents to ricky@enhancedbenefitsok.com
Should be Empty:

Benefit Administration System Set Up Form

Employee Qualification Info

Medical Plan Information

Dental Plan Information

Vision Plan Information

Short-Term Disability Plan Information

Long-Term Disability Plan Information

Basic Life Plan Information

Voluntary Life Plan Information

Other Contributions

Other Documents for the Benefit Admin System