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.

Thanks for partnering with Velocity Benefits!
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 *
Velocity Rep's Name *
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
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)
Type a question
EDI Contact Name

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

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
Miscelanious Plan
Type a question
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

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Medical Plan Docs

Browse Files

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Dental Plan Docs

Browse Files

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Vision Plan Docs

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Cancel of
Disability Plan Docs

Browse Files

Cancel of
Life Plan Docs

Browse Files

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Work-site Plan Docs

Browse Files

Cancel of
TPI - XML Sheet

Browse Files

Cancel of
Other Docs

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Cancel of
Other Docs

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Cancel of
Other Docs

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Cancel of
Should be Empty:

Case Build Submission Form

Company and Contact Info

Class Structure and Product Offering

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