Digital Flyer Request Form

• Agent First Name *
• Agent Last Name *
• Agent Email * - Email Address Other Than Carrier Specific (e.g. Aflac)
• Agent Phone Number
• MWE Partnership Account Manager
• Group/Company Name *
• Group/Company Name *
• Group/Company Website
• Enrollment Start Date *
• Enrollment End Date *
• What voluntary products are being enrolled *

  	Enrollment Type	Carrier	Product Name
  Accident	—Please choose an option—New ProductRe-enrollment
  Cancer	—Please choose an option—New ProductRe-enrollment
  Critical Illness	—Please choose an option—New ProductRe-enrollment
  Disability	—Please choose an option—New ProductRe-enrollment
  Hospital Indemnity	—Please choose an option—New ProductRe-enrollment
  Term Life	—Please choose an option—New ProductRe-enrollment
  Whole/UL Life	—Please choose an option—New ProductRe-enrollment
  Identity Theft	—Please choose an option—New ProductRe-enrollment

• Who will be handling enrollment? * AgentMWE Partnership
• Do you have a census that includes cell phone numbers and emails? * YesCell OnlyEmail OnlyNo
• How will employees be communicated with? * Email OnlyText and EmailText OnlyInternal Group Communication
• Do you want to use our auto-scheduler Tool? * YesNo
• Upload Census/Logos/Headshots/Brochures/Claim Forms You Want To Use
• Please include any other information you believe may be helpful

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