Language
English (US)
Company/Case Information
Which company/organization is this case build for?
Company Name
Company Tax ID
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Logo
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Broker/Agency Information
Who is submitting this case for build?
Submitted By
First Name
Last Name
Primary Broker Contact
First Name
Last Name
Brokerage/Agency
Broker Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Additional Contacts
Add additional broker/agency and HR contacts below.
Broker Contacts
HR Contacts
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Group/Enrollment Specifications
Key metadata for services offered and timeline creation.
Effective Date
-
Month
-
Day
Year
Date
Open Enrollment Start Date
-
Month
-
Day
Year
Date
Open Enrollment End Date
-
Month
-
Day
Year
Date
Enrollment Method(s)
Self Service
Call Center
Face-to-Face
# of Employees
# of Benefit Eligible Employees
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Job Classes & Products
Key metadata for the case build to drive benefits rules & eligibility.
# Job Classes
# of Locations
Job Classes
Class Name
Pay Frequencies
Waiting Period (days)
Benefits Eligibility
Termination
Job Class 1
52 pay
26 pay
24 pay
12 pay
11 pay
10 pay
9 pay
date of hire
first of month after
first of month
other
date of termination
end of month
other
Job Class 2
52 pay
26 pay
24 pay
12 pay
11 pay
10 pay
9 pay
date of hire
first of month after
first of month
other
date of termination
end of month
other
Job Class 3
52 pay
26 pay
24 pay
12 pay
11 pay
10 pay
9 pay
date of hire
first of month after
first of month
other
date of termination
end of month
other
Job Class 4
52 pay
26 pay
24 pay
12 pay
11 pay
10 pay
9 pay
date of hire
first of month after
first of month
other
date of termination
end of month
other
Job Class 5
52 pay
26 pay
24 pay
12 pay
11 pay
10 pay
9 pay
date of hire
first of month after
first of month
other
date of termination
end of month
other
Job Class 6
52 pay
26 pay
24 pay
12 pay
11 pay
10 pay
9 pay
date of hire
first of month after
first of month
other
date of termination
end of month
other
Job Class 7
52 pay
26 pay
24 pay
12 pay
11 pay
10 pay
9 pay
date of hire
first of month after
first of month
other
date of termination
end of month
other
Benefits Offered
Medical
Dental
Vision
FSA
HSA
HRA
Short-Term Disability
Long-Term Disability
Basic Life
Voluntary Life
Permanent Life
Accident
Critical Illness
Hospitalization
Notes on Classes and Product Offerings:
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Data & Benefits Administration
Requirements for data, 834 files, EDI feeds, and benefits admin options.
System Status
Open Enrollment Only
OE + Benefit Administration
EDI Needed?
Yes
No
Additional cost may apply
EDI Point of Contact
First Name
Last Name
EDI POC Email
example@example.com
EDI POC Phone
-
Area Code
Phone Number
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Medical
How many medical plans?
1
2
3
4
5+
Medical Plans
Medical Plan 1 Rates
*
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Medical Plan 1 Notes
Medical Plan 2 Rates
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Medical Plan 2 Notes
Medical Plan 3 Rates
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Medical Plan 3 Notes
Medical Plan 4 Rates
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Medical Plan 4 Notes
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Dental
How many dental plans?
1
2
3
4
5+
Dental Plans
Dental Plan 1 Rates
*
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Dental Plan 1 Notes
Dental Plan 2 Rates
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Dental Plan 2 Notes
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Vision
How many vision plans?
1
2
3
4
5+
Vision Plans
Vision Plan 1 Rates
*
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Vision Plan 1 Notes
Vision Plan 2 Rates
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Vision Plan 2 Notes
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FSA, HRA, HSA
FSA Carrier
FSA Plan Name
FSA Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Maximum Annual FSA Election
Minimum Annual FSA Election
Mid Year New Hire Max Monthly Contribution
Pro-rata
Full amount
FSA Notes/Comments
Is there a DCA (Dependent Care Account?)
yes
no
DCA Carrier
DCA Plan Name
DCA Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Maximum Annual DCA Election
Minimum Annual DCA Election
Mid Year New Hire Max Monthly Contribution
Pro-rata
Full amount
DCA Notes/Comments
HRA Carrier
HRA Plan Name
Tied to which medical plan?
HRA Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
HRA Monthly Contributions
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Medicare
Domestic Partner
Mid-year New Hires Employer Contribution
Pro-rata
Full amount
Employer funding for account
1st of the following month
1st of the month
HRA Notes/Comments
HSA Carrier
HSA Plan Name
Tied to which medical plan?
HSA Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
HSA Monthly Contributions
Monthly Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Medicare
Domestic Partner
Mid-year New Hires Employer Contribution
Pro-rata
Full amount
Employer funding for account
1st of the following month
1st of the month
Allow employee to contribute?
yes
no
HSA Notes/Comments
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Short-Term Disability
STD Carrier
STD Plan Name
STD Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
STD Eligibility Rules
Coverage Begins
Waiting Period (days)
Termination Date
Restrictions or Contingencies?
If yes, please describe.
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Type of Benefit
% of earnings
incremental
% of weekly earnings
Increment Amount
Minimum weekly benefit
Maximum weekly benefit
New Hire/Newly Eligible GI Amount
Late Entrant GI Amount
Re-enrollment GI Rule
Rounding
Require enrollment?
yes
no
Employer contribution
%
$
Employer contribution amount
Accident waiting period (days)
Sickness waiting period (days)
Benefit period (weeks)
Monthly Rates per $10 of Weekly Benefit
STD Notes/Comments
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Long-Term Disability
LTD Carrier
LTD Plan Name
LTD Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
LTD Eligibility Rules
Coverage Begins
Waiting Period (days)
Termination Date
Restrictions or Contingencies?
If yes, please describe.
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Type of Benefit
% of earnings
incremental
% of monthly earnings
Increment Amount
Minimum monthly benefit
Maximum monthly benefit
New Hire/Newly Eligible GI Amount
Late Entrant GI Amount
Re-enrollment GI Rule
Rounding
Require enrollment?
yes
no
Employer contribution
%
$
Employer contribution amount
Waiting period (days)
Benefit period (i.e. Age 65)
Monthly Rates per $100 of Covered Payroll
LTD Notes/Comments
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Basic Life
Basic Life Carrier
Life Plan Name
Life Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Life Eligibility Rules
Start Date
Termination Date
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Capture beneficiary?
yes
no
optional
Require enrollment?
yes
no
Benefit Amount
AD&D Offered?
yes
no
Combine life & AD&D?
yes
no
Life rate per $1,000
AD&D rate per $1,000
Rounding
Employer contribution
%
$
Employer contribution amount
Age Reductions
Basic Life Notes/Comments
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Voluntary Life
Vol Life Carrier
Life Plan Name
Life Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Life Eligibility Rules
Multiple of salary
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Capture beneficiary?
Require enrollment?
yes
no
Minimum benefit
Maximum benefit
AD&D Offered?
yes
no
Combine life & AD&D?
yes
no
Rounding
Employee Monthly Rates per $1,000 of Benefit
Spouse Monthly Rates per $1,000 of Benefit
Child Monthly Rates per $1,000 of Benefit
AD&D rate per $1,000
Employer contribution
%
$
Employer contribution amount
New Hire/Newly Eligible GI Amount
Late Entrant GI Amount
Re-enrollment GI Rule
Age Reductions
Vol Life Notes/Comments
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Permanent Life
Perm Life Carrier
Life Plan Name
Life Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Life Eligibility Rules
Multiple of salary
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
Capture beneficiary?
Require enrollment?
yes
no
Life rate per $1,000
Female Smoker Rate per $1000
Female Non-Smoker Rate per $1000
Male Smoker Rate per $1000
Male Non-Smoker Rate per $1000
Benefit as a % of weekly earnings
Rounding
Minimum weekly benefit
Maximum weekly benefit
Employer contribution
%
$
Employee Monthly Rates per $1,000 of Benefit
GI Amount
Employer contribution amount
Age Reductions
Permanent Life Notes/Comments
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Accident
Accident Carrier
Accident Plan Name
Accident Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Accident Eligibility Rules
Coverage Begins
Waiting Period (days)
Termination Date
Restrictions or Contingencies?
If yes, please describe.
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Accident Plan Rates
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Accident Notes/Comments
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Critical Illness
CI Carrier
CI Plan Name
CI Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
CI Eligibility Rules
Coverage Begins
Waiting Period (days)
Termination Date
Restrictions or Contingencies?
If yes, please describe.
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Employee Monthly Rates per $1,000 of Benefit
Spouse Monthly Rates per $1,000 of Benefit
Child Monthly Rates per $1,000 of Benefit
CI Notes/Comments
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Hospitalization
Hospitalization Carrier
Hospitalization Plan Name
Hospitalization Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Hospitalization Eligibility Rules
Coverage Begins
Waiting Period (days)
Termination Date
Restrictions or Contingencies?
If yes, please describe.
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Hospitalization Plan Rates
Monthly Rate
Monthly Employer Contribution
Employee
Employee + Spouse
Employee + Child
Employee + Children
Family
Hospitalization Notes/Comments
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Other
Other Plan 1 Carrier
Other Plan 1 Name
Other Plan 1 Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Other Plan 1 Eligibility Rules
Coverage Begins
Waiting Period (days)
Termination Date
Restrictions or Contingencies?
If yes, please describe.
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Other Plan 1 Notes/Comments
Other Plan 2 Carrier
Other Plan 2 Name
Other Plan 2 Eligibility
All
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Other Plan 2 Eligibility Rules
Coverage Begins
Waiting Period (days)
Termination Date
Restrictions or Contingencies?
If yes, please describe.
Class 1
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 2
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 3
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 4
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 5
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 6
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Class 7
1st of Month (FOM)
Date of Hire (DOH)
FOM after DOH
End of Month
Date of Event
No
Yes
Other Plan 2 Notes/Comments
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Census, Plan Design, In-Force, Eligibility Files
Upload all relevant files as needed below.
Census Upload
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Medical Plan Docs
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Dental Plan Docs
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Vision Plan Docs
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Disability Plan Docs
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Life Plan Docs
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Worksite Plan Docs
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Other Docs
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