NASU Group Setup

Account Set Up Form

CASE Program

Group Contact Information
Company Name:
Corporate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact @ Employer Group

First NameLast Name
Title
Phone Number

Area CodePhone Number
Email
example@example.com

Group Information
Additional DBA's that may be used to identify your organization:
Number of Benefit Eligible Employees
Number of Benefit Eligible Employees (64+)
CASE Effective Date

MonthDayYear
Date
Please list additional locations:
Anything you would like to share with TBG to assist with launching your account?

Additional Group Contacts:
Additional Group: Contacts

Consultant Contacts
Consultant Firm:
Consultant Point of Contact:

First NameLast Name
Consultant Email
example@example.com
Consultant Phone Number

Area CodePhone Number
Additional Consultant Contacts

Pricing and Implementation Fees
Program Selection- Choose one
prevnext( X )
Under 500 Employees$250.00
Ongoing Monthly Fee

Quantity

Over 500 Employees$0.50
Ongoing Monthly Fee

Number of Benefit Elig Employees
Item subtotal:$0.00

Implementation Fee$1,500.00
One-time fee

Quantity

Total $0.00
Preferred Invoice Recipient
example@example.com

Agreement and Signature
Once this form is received, an invoice will populate and send electronically.

I agree to the terms outlined and confirm that all provided information is true and accurate, should company or contact information change it is the sole responsibility of the company to notify Transitions Retiree Benefit Group with updated contact information.
Signature

Clear
Title
Date

MonthDayYear
Date
Should be Empty: