Case Build Request Company Name * Street Address * Street Address Line 2 City * State/Province * Postal/Zip Code * Country * —Please choose an option—United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRepublic of the CongoRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSouth SudanSpainSri LankaSudanSurinameSvalbardeSwatiniSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsIsle of ManUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOtherContact InfoContact NamePhoneEmailBusiness HR Contact - PrimaryBusiness Contact Info - SecondaryBroker Contact Info - PrimaryBroker Contact Info - SecondaryName of Brokerage Enrollment DatesStart Date of Enrollment * Plan Effective Date * Business BasicsType of Business Tax ID # of Employees Number of Benefit Classes Number of Locations Payroll Cycle WeeklyBi-WeeklySemi-MonthlyMonthlyReporting Info - Required Info for ReportingLocations —Please choose an option—YesNoOther —Please choose an option—YesNo* Please note that if locations, job titles or any other info is required for reporting, then they need to be on the census at time of submission.Company Logo Employee ClassesIf all employees are considered to be part of the same class, then only “Class 1” needs to be completed.Class NameNumber of Pay CyclesWaiting PeriodBenefits EligibilityClass 1Class 2Class 3Date of First Payroll After Effective Date * Date of Second Payroll After Effective Date * Please select the plans below that are being offered:Check the Plans Being OfferedName of CarrierNumber of PlansPretax (Check if Yes)MedicalYesYesDentalYesYesVisionYesYesBasic LifeYesYesVoluntary LifeYesYesShort Term DisabilityYesYesLong Term DisabilityYesYesNotes on Classes and Product Offerings: How will Open Enrollment be Conducted? Check all that apply: Face-to-FaceTelephonicSelf-ServiceEDI Needed (Additional Costs May Apply) YesNoMedicalMedical Plan 1: Name Medical Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Medical Plan 1 Rates (Just Need Employer OR Employee Contributions)Monthly RateMonthly Employer ContributionEmployee Monthly ContributionEmployeeEmployee/SpouseEmployee/ChildEmployee/ChildrenFamilyMedical Plan 2: Name Medical Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Medical Plan 2 Rates (Just Need Employer OR Employee Contributions)Monthly RateMonthly Employer ContributionEmployee Monthly ContributionEmployeeEmployee/SpouseEmployee/ChildEmployee/ChildrenFamilyMedical Plan 3: Name Medical Plan 3: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Medical Plan 3 Rates (Just Need Employer OR Employee Contributions)Monthly RateMonthly Employer ContributionEmployee Monthly ContributionEmployeeEmployee/SpouseEmployee/ChildEmployee/ChildrenFamilyNotes for Medical Plans: DentalDental Plan 1: Name Dental Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Dental Plan 1 Rates (Just Need Employer OR Employee Contributions)Monthly RateMonthly Employer ContributionEmployee Monthly ContributionEmployeeEmployee/SpouseEmployee/ChildEmployee/ChildrenFamilyDental Plan 2: Name Dental Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Dental Plan 2 Rates (Just Need Employer OR Employee Contributions)Monthly RateMonthly Employer ContributionEmployee Monthly ContributionEmployeeEmployee/SpouseEmployee/ChildEmployee/ChildrenFamilyNotes for Dental Plans: VisionVision Plan 1: Name Vision Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Vision Plan 1 Rates (Just Need Employer OR Employee Contributions)Monthly RateMonthly Employer ContributionEmployee Monthly ContributionEmployeeEmployee/SpouseEmployee/ChildEmployee/ChildrenFamily[text vision-plan-3-family-monthly-employer-contribution[text vision-plan-3-family-employee-monthly-contribution]Vision Plan 2: Name Vision Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Vision Plan 2 Rates (Just Need Employer OR Employee Contributions)Monthly RateMonthly Employer ContributionEmployee Monthly ContributionEmployeeEmployee/SpouseEmployee/ChildEmployee/ChildrenFamily[text vision-plan-2-family-monthly-employer-contribution[text vision-plan-2-family-employee-monthly-contribution]Notes for Vision Plans: Disability RatesShort Term DisabilityShort Term Disability Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Short Term Disability Employer PaidSTD Details% of Weekly Earnings Rounding Type —Please choose an option—Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000Rounding To —Please choose an option—UpMinimum Benefit Maximum Benefit Waiting Period Benefit Period Short Term Disability Monthly Rate per $10 of BenefitEmployee Monthly Rate18-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-plusShort Term Disability Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Short Term Disability Employer PaidNotes for Short Term Disability: Long Term DisabilityLong Term Disability Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Long Term Disability Employer PaidLTD Details% of Monthlyly Earnings Rounding Type —Please choose an option—Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000Rounding To —Please choose an option—UpMinimum Benefit Maximum Benefit Waiting Period Benefit Period Long Term Rates will be: —Please choose an option—Per $100 of Covered PayrollPer $100 of BenefitEmployee Monthly Rate18-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-plusLong Term Disability Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Long Term Disability Employer PaidLTD Details% of Monthly Earnings Rounding Type —Please choose an option—Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000Rounding To —Please choose an option—UpMinimum Benefit Maximum Benefit Waiting Period Benefit Period Long Term Rates will be: —Please choose an option—Per $100 of Covered PayrollPer $100 of BenefitEmployee Monthly Rate18-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970+Notes for Long Term Disability: Life RatesBasic LifeBasic Life: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Basic Life Employer PaidBenefit Amount: Monthly Rate per $1000 of Benefit18-2425-2930-3435-3940-4445-49[text [text basic-life-45-49-monthly-rate-per-1000-dollars-of-benefit]50-5455-59[text [text basic-life-55-59-monthly-rate-per-1000-dollars-of-benefit]60-6465-6970-7475-plusAge ReductionStarting AgeEnding Age% Reduced ByNotes on Basic Life: Voluntary LifeVoluntary Life: Which Classes are eligible for this plan? AllClass 1Class 2Class 3Basic Life Monthly Rate per $1000 of Benefit(include AD&D rate with Basic Life if applicable)Benefit Amount LimitsMinimum Benefit AmountMaximum Benefit AmountMultiple of Salary Limit% of Employee ElectionEmployeeSpouseDependentsDependent EligibilityMinimum Dependent Age Maximum Dependent Age Maximum Student Age Guarantee Issue LimitsInitial Open Enrollment/New HiresLate Entrants/Did Not Sign Up InitiallyExisting Enrollment/Increasing CoverageEmployeeSpouseEmployeeLife Rate RulesSpouse Rates Match Employee? —Please choose an option—YesNoDependents Rates Based on Age of Employee? —Please choose an option—YesNoLife and AD&D Combined? —Please choose an option—YesNoRates Based on Tobacco Use? —Please choose an option—YesNo#########When age-band changes, update rates on —Please choose an option—First Month FollowingPolicy AnniversaryBirthdayWhen age reductions occur, reduce benefits on —Please choose an option—First Month FollowingPolicy AnniversaryBirthdayWhen age-band changes, reduce benefits on —Please choose an option—First Month FollowingPolicy AnniversaryBirthdayWhen age reductions occur, reduce benefits on —Please choose an option—First Month FollowingPolicy AnniversaryBirthdayVoluntary Life Monthly Rate per $1000 of BenefitEmployeeSpouseTobacco EmployeeTobacco Spouse18-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475+Age ReductionStarting AgeEnding Age% Reduced ByDependent Rate per $1,000 Notes on Voluntary Life: FSA, HSA, HRABeing OfferedEmployer ContributionFSAYesHSAYesHRAYesΔ