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
Your Email
example@example.com
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
Other
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
Please Select
Open Enrollment Only
OE + Benefit Administration
EDI Needed?
Please Select
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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Census Data
Requirements to setup your case.
Please use this template to convert your data for case setup. This form is secure.
Census Upload
Employee & Dependent Data. Please use template provided above.
Plan Docs
Browse Files
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