Case Build Submission Form

Case Build Submission Form
"Good data in equals good data out."

Please fill out the fields below, add any notes for the plans and attach all plan docs on the last page.

We will need a census, click the link and download our census template. All highlighted fields are required. Phone numbers and email addresses are also highly encouraged. Load your Census on the very last page of this document.

https://hubs.ly/H0Jx6HN0

Once you are finished with everything just hit submit on the last page.

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Company and Contact Info
Company Name *

	Type of Business	SIC Rating	Tax ID
.

Company Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Who is Submitting this case? *

First Name Last Name
Submitter Email
Submitter Phone

Area Code Phone Number
Name of Brokerage
Broker Contact Info
HR Contact Info
Enrollment Effective Date *

Month Day Year
Date
Open Enrollment Start Date *

Month Day Year
Date
Open Enrollment End Date *

Month Day Year
Date
Dates of First Two Pay Cycles After the Effective Date *
Class Structure and Product Offering
* Please note that if locations, job titles, or any other info is required for reporting then they need to be on the census at the time of submission.

	Number of Benefit Classes	# of Eligible Employees	Number of Locations	Locations Required on Reporting?
.

Classes *

	Class Name	Number of Pay Cycles	Waiting Period	Benefits Eligibility	Termination Day	Employee Change Frequency
Class 1
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7
Class 8
Class 9
Class 10

*
Notes on Classes and Product Offerings:
How will Open Enrollment be Conducted? Check all that apply:

Face to Face Telephonic Self-Service
*If its self-serve do you want system generated welcome emails/Enrollment Emails?
Will the platform be left behind as a Benefits Admin system?
Will this be built on our license or do you have your own license?
Will File Feeds Be Needed?(Additional Costs Could Apply Depending on Carrier - $1,000 Set up fee - $1 PEPM)
EDI Contact Name

First Name Last Name
EDI Point of Contact Email
example@example.com

	Minimum Dependent Age	Maximum Dependent Age	Maximum Student Age
Dependents

	Minimum Dependent Age	Maximum Dependent Age	Maximum Student Age
Dependents

Work-site
Accident
Carrier Name
Plan Name

Accident Rates

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

Accident Plan Notes
Hospital Indemnity
Carrier Name
Plan Name

Hospital Indemnity Rates

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

Hospital Plan Notes
Gap Plan
Carrier Name
Plan Name

Gap Plan Rates

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

Gap Plan Notes
Critical Illness

*Note - rater per $1,000 are required for CI - please request from the carrier if you do not have them in this format.
Carrier Name
Plan Name

Critical Illness Rate per $1,000 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+

Critical Illness Plan Notes
Cancer Only
Carrier Name
Plan Name
Spouse Rate Same as Employee?
Rates Based on Tobacco Use?

Cancer Rates

	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+

Cancer Plan Notes
Miscellaneous Plan
Carrier Name
Plan Name

Miscellaneous Rates

	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+

Miscellaneous Plan Rates

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

Notes on Work-site Products

FSA, HSA, HRA

	Being Offered	Carrier Name	Employer Contribution	Annual Limits
FSA
HSA
HRA

Census and Plan Doc Uploads
Company Logo

Browse Files

Cancel of
Census Upload

Browse Files

Cancel of
Medical Plan Docs

Browse Files

Cancel of
Dental Plan Docs

Browse Files

Cancel of
Vision Plan Docs

Browse Files

Cancel of
Disability Plan Docs

Browse Files

Cancel of
Life Plan Docs

Browse Files

Cancel of
Work-site Plan Docs

Browse Files

Cancel of
TPI - XML Sheet

Browse Files

Cancel of
Other Docs

Browse Files

Cancel of
Other Docs

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Cancel of
Other Docs

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Cancel of
Should be Empty:

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

	Update Rates On	Reduce Benefits On
When age-band changes
When Age reductions occur

	Starting Age	Ending Age	% Reduced By:
Age Reduction
Age Reduction
Age Reduction
Age Reduction

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

	Update Rates On	Reduce Benefits On
When age-band changes
When Age reductions occur

Case Build Submission Form

Company and Contact Info

Class Structure and Product Offering

Medical

Medical

Medical

Medical

Medical

Dental

Dental

Vision

Vision

Short Term Disability

Short Term Disability

Long Term Disability

Long Term Disability

Basic Life

Basic Life

Voluntary Life Plan 1

Voluntary Life

Work-site

FSA, HSA, HRA

Census and Plan Doc Uploads

	Open Enrollment	Late Entrants	Existing Enrollment
Employee
Spouse
Dependents

	Open Enrollment	Late Entrants	Existing Enrollment
Employee
Spouse
Dependents