• 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.  Once you are finished just hit submit on the last page.  Thanks for partnering with Velocity Benefits!   

     

  • Company and Contact Info

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  • 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.
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  • Medical

    Plan 1
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  • Medical

    Plan 2
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  • Medical

    Plan 3
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  • Medical

    Plan 4
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  • Dental

    Plan 1
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  • Dental

    Plan 2
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  • Vision

    Plan 1
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  • Vision

    Plan 2
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  • Short Term Disability

    Plan 1
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  • Short Term Disability

    Plan 2
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  • Long Term Disability

    Plan 1
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  • Long Term Disability

    Plan 2
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  • Basic Life

    Plan 1
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  • Basic Life

    Plan 2
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  • Voluntary Life Plan 1

    Plan 1
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  • Voluntary Life

    Plan 2
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  • Work-site

  • Accident 

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  • Hospital Indemnity 

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  • Gap Plan 

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  • 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.

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  • Cancer Only 

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  • Miscelanious Plan 

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  • FSA, HSA, HRA

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  • Census and Plan Doc Uploads

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