Case Build Request

• Company Name *
• Street Address *
• Street Address Line 2
• City *
• State/Province *
• Postal/Zip Code *
• Country * ---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 SaharaYemenZambiaZimbabweOther

Contact Info

• Name of Brokerage

Enrollment Dates

• Start Date of Enrollment *
• Plan Effective Date *

Business Basics

• Type of Business
• Tax ID
• # of Employees
• Number of Benefit Classes
• Number of Locations
• Payroll Cycle WeeklyBi-WeeklySemi-MonthlyMonthly

Reporting Info - Required Info for Reporting

• Locations ---YesNo
• Other ---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 Classes

If all employees are considered to be part of the same class, then only “Class 1” needs to be completed.

• Date 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 Offered	Name of Carrier	Number of Plans	Pretax (Check if Yes)
  Medical	Yes			Yes
  Dental	Yes			Yes
  Vision	Yes			Yes
  Basic Life	Yes			Yes
  Voluntary Life	Yes			Yes
  Short Term Disability	Yes			Yes
  Long Term Disability	Yes			Yes

• Notes on Classes and Product Offerings:
• How will Open Enrollment be Conducted? Check all that apply: Face-to-FaceTelephonicSelf-Service
• EDI Needed (Additional Costs May Apply) YesNo

Medical

• Medical Plan 1: Name
• Medical Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Medical Plan 1 Rates (Just Need Employer OR Employee Contributions)

	Monthly Rate	Monthly Employer Contribution	Employee Monthly Contribution
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family

• Medical Plan 2: Name
• Medical Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Medical Plan 2 Rates (Just Need Employer OR Employee Contributions)

	Monthly Rate	Monthly Employer Contribution	Employee Monthly Contribution
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family

• Medical Plan 3: Name
• Medical Plan 3: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Medical Plan 3 Rates (Just Need Employer OR Employee Contributions)

	Monthly Rate	Monthly Employer Contribution	Employee Monthly Contribution
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family

• Notes for Medical Plans:

Dental

• Dental Plan 1: Name
• Dental Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Dental Plan 1 Rates (Just Need Employer OR Employee Contributions)

	Monthly Rate	Monthly Employer Contribution	Employee Monthly Contribution
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family

• Dental Plan 2: Name
• Dental Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Dental Plan 2 Rates (Just Need Employer OR Employee Contributions)

	Monthly Rate	Monthly Employer Contribution	Employee Monthly Contribution
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family

• Notes for Dental Plans:

Vision

• Vision Plan 1: Name
• Vision Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Vision Plan 1 Rates (Just Need Employer OR Employee Contributions)

	Monthly Rate	Monthly Employer Contribution	Employee Monthly Contribution
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family

• Vision Plan 2: Name
• Vision Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Vision Plan 2 Rates (Just Need Employer OR Employee Contributions)

	Monthly Rate	Monthly Employer Contribution	Employee Monthly Contribution
Employee
Employee/Spouse
Employee/Child
Employee/Children
Family

• Notes for Vision Plans:

Short Term Disability

• Short Term Disability Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Short Term Disability Employer Paid

STD Details

• % of Weekly Earnings
• Rounding Type ---Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000
• Rounding To ---Up
• Minimum Benefit
• Maximum Benefit
• Waiting Period
• Benefit Period

Short Term Disability Monthly Rate per $10 of Benefit

	Employee Monthly Rate
18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-plus

• Short Term Disability Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Short Term Disability Employer Paid
• Notes for Short Term Disability:

Long Term Disability

• Long Term Disability Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Long Term Disability Employer Paid

LTD Details

• % of Monthlyly Earnings
• Rounding Type ---Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000
• Rounding To ---Up
• Minimum Benefit
• Maximum Benefit
• Waiting Period
• Benefit Period
• Long Term Rates will be: ---Per $100 of Covered PayrollPer $100 of Benefit

	Employee Monthly Rate
18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-plus

• Long Term Disability Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Long Term Disability Employer Paid

LTD Details

• % of Monthly Earnings
• Rounding Type ---Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000
• Rounding To ---Up
• Minimum Benefit
• Maximum Benefit
• Waiting Period
• Benefit Period
• Long Term Rates will be: ---Per $100 of Covered PayrollPer $100 of Benefit

	Employee Monthly Rate
18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+

• Notes for Long Term Disability:

Basic Life

• Basic Life: Which Classes are eligible for this plan? AllClass 1Class 2Class 3
• Basic Life Employer Paid
• Benefit Amount:

	Monthly Rate per $1000 of Benefit
18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-plus

​

Age Reduction

Starting Age	Ending Age	% Reduced By

• Notes on Basic Life:

Voluntary Life

• Voluntary Life: Which Classes are eligible for this plan? AllClass 1Class 2Class 3

Basic Life Monthly Rate per $1000 of Benefit

(include AD&D rate with Basic Life if applicable)

Benefit Amount Limits

	Minimum Benefit Amount	Maximum Benefit Amount	Multiple of Salary Limit	% of Employee Election
Employee
Spouse
Dependents

Dependent Eligibility

• Minimum Dependent Age
• Maximum Dependent Age
• Maximum Student Age

Guarantee Issue Limits

	Initial Open Enrollment/New Hires	Late Entrants/Did Not Sign Up Initially	Existing Enrollment/Increasing Coverage
Employee
Spouse
Employee

Life Rate Rules

• Spouse Rates Match Employee? ---YesNo
• Dependents Rates Based on Age of Employee? ---YesNo
• Life and AD&D Combined? ---YesNo
• Rates Based on Tobacco Use? ---YesNo

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• When age-band changes, update rates on ---First Month FollowingPolicy AnniversaryBirthday
• When age reductions occur, reduce benefits on ---First Month FollowingPolicy AnniversaryBirthday
• When age-band changes, reduce benefits on ---First Month FollowingPolicy AnniversaryBirthday
• When age reductions occur, reduce benefits on ---First Month FollowingPolicy AnniversaryBirthday

Voluntary Life Monthly Rate per $1000 of Benefit

	Employee	Spouse	Tobacco Employee	Tobacco Spouse
18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+

Age Reduction

Starting Age	Ending Age	% Reduced By

• Dependent Rate per $1,000
• Notes on Voluntary Life:

FSA, HSA, HRA