Pre-Enrollment Worksheet
Case Name
*
Broker or Agent Name
*
First Name
Last Name
Broker or Agent Email
*
example@example.com
Velocity Rep Name
*
First Name
Last Name
State of Case
*
Employee Count
*
Number of Locations
*
Effective Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Enrollment Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Start Date
Enrollment End Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
End Date
Which Technology (if applicable)
*
Employee Navigator
Ease
Other
What Pre-enrollment Communication is Velocity providing?
*
Video
Benefit Snapshot
Text
Email
None Needed
Method of Communication
*
Text
Email
Both
Not applicable to this case
If you are wanting call center enrollment - what hours do you prefer (not guaranteed but we will do our best to accommodate)?
*
Bilingual Counselors Needed?
*
Yes
No
What Language?
*
Face to Face Details - How Many Locations? What States? Other Details:
*
Will new ID cards be issued and for what products and when can employees expect to receive them?
*
Who should employees contact throughout the year if they have benefit questions and what is their contact info?
*
Do employees have to complete their enrollment if they wish to decline all coverage?
*
Will coverage remain the same (rollover) if they do not complete their enrollment?
*
Is the company trying to drive participation to a specific product (HDHP, HSA, ETC)?
*
If certain lines of coverage are changing carriers, will any of the old policies with the former carrier still be payroll deducted?
*
Other information we should know about the Group? For example: Carrier Challenges, Key Employee Turnover, Deductible Going Up, Jump in Medical Rates, Merger, Operates Under Different Names in Various Locations.
*
Add any applicable files for benefits counselors to reference (Benefit Guides, PPT Presentations, Notes, Plan Docs if they have not been submitted somewhere else).
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