Skip Navigation

Case Build Request

    Contact Info

    Contact NamePhoneEmail
    Business HR Contact - Primary
    Business Contact Info - Secondary
    Broker Contact Info - Primary
    Broker Contact Info - Secondary

    Enrollment Dates

    Business Basics

    Reporting Info - Required Info for Reporting

    • * 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.

    Employee Classes

    If 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 Eligibility
    Class 1
    Class 2
    Class 3
    • Check the Plans Being OfferedName of CarrierNumber of PlansPretax (Check if Yes)
      Medical
      Dental
      Vision
      Basic Life
      Voluntary Life
      Short Term Disability
      Long Term Disability

    Medical

    • Monthly RateMonthly Employer ContributionEmployee Monthly Contribution
      Employee
      Employee/Spouse
      Employee/Child
      Employee/Children
      Family
    • Monthly RateMonthly Employer ContributionEmployee Monthly Contribution
      Employee
      Employee/Spouse
      Employee/Child
      Employee/Children
      Family
    • Monthly RateMonthly Employer ContributionEmployee Monthly Contribution
      Employee
      Employee/Spouse
      Employee/Child
      Employee/Children
      Family

    Dental

    • Monthly RateMonthly Employer ContributionEmployee Monthly Contribution
      Employee
      Employee/Spouse
      Employee/Child
      Employee/Children
      Family
    • Monthly RateMonthly Employer ContributionEmployee Monthly Contribution
      Employee
      Employee/Spouse
      Employee/Child
      Employee/Children
      Family

    Vision

    • Monthly RateMonthly Employer ContributionEmployee Monthly Contribution
      Employee
      Employee/Spouse
      Employee/Child
      Employee/Children
      Family[text vision-plan-3-family-monthly-employer-contribution[text vision-plan-3-family-employee-monthly-contribution]
    • Monthly RateMonthly Employer ContributionEmployee Monthly Contribution
      Employee
      Employee/Spouse
      Employee/Child
      Employee/Children
      Family[text vision-plan-2-family-monthly-employer-contribution[text vision-plan-2-family-employee-monthly-contribution]

    Disability Rates

    Short Term Disability

    • STD Details

    • 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

    Long Term Disability

    • LTD Details

    • 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
    • LTD Details

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

    Life Rates

    Basic Life

    • Monthly Rate per $1000 of Benefit
      18-24
      25-29
      30-34
      35-39
      40-44
      45-49[text [text basic-life-45-49-monthly-rate-per-1000-dollars-of-benefit]
      50-54
      55-59[text [text basic-life-55-59-monthly-rate-per-1000-dollars-of-benefit]
      60-64
      65-69
      70-74
      75-plus

      Age Reduction

      Starting AgeEnding Age% Reduced By

    Voluntary Life

    • Basic Life Monthly Rate per $1000 of Benefit

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

      Benefit Amount Limits

      Minimum Benefit AmountMaximum Benefit AmountMultiple of Salary Limit% of Employee Election
      Employee
      Spouse
      Dependents

      Dependent Eligibility

    • Guarantee Issue Limits

      Initial Open Enrollment/New HiresLate Entrants/Did Not Sign Up InitiallyExisting Enrollment/Increasing Coverage
      Employee
      Spouse
      Employee

      Life Rate Rules

    • #########

    • Voluntary Life Monthly Rate per $1000 of Benefit

      EmployeeSpouseTobacco EmployeeTobacco 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 AgeEnding Age% Reduced By

    FSA, HSA, HRA

    Being OfferedEmployer Contribution
    FSA
    HSA
    HRA

    Ready to Get Started?

    Contact The MWE Partnership today to schedule an appointment.

    Contact Us Now