Assurity New Business Transmittal and Contest Tracking Tool

1
Today's Date
Date
Month
Day
Year
2
Type of enrollment:* This field is required.
Open Enrollment
New Hire(s)
Qualified Changes
Other
3
#1 Writing Agent's Name* This field is required.
First Name
Last Name
4
#1 Writing Agent's Email* This field is required.
example@example.com
5
Case Status* This field is required.
New Account (first transmittal for this group)
Add to an existing account
6
Group Name* This field is required.
7
How many POLICYHOLDERS did you enroll on this Assurity Transmittal? * This field is required.
8
How many total ASSURITY POLICIES (not policyholders) are written on this transmittal?* This field is required.
9
What's the TOTAL Amount of ASSURITY AP WRITTEN IN THIS ENROLLMENT?* This field is required.Type in the exact AP (do not round up) with no Dollar Sign... use a decimal and do not use a "$" symbol.
This format please: If you wrote $21,380.82 you would type in: 21380.82
10
Effective Date for these policies:* This field is required.
Date
Month
Day
Year
11
How many agents are on this transmittal?* This field is required.
Please Select
Please Select
1
2
3
4
5
12
Agent#1 Name * Agent# Producer Code# * % of Split % goes here *
13
Agent#2 Name * Agent# Producer Code# * % of Split % goes here *
14
Agent#3 Name * Agent# Producer Code# * % of Split % goes here *
15
Agent#4 Name * Agent# Producer Code# * % of Split % goes here *
16
Agent#5 Name * Agent# Producer Code# * % of Split % goes here *
17
IMPORTANT NOTICE - IF Splitting this case... the WRITING Agent listed below will receive Case Count Credit for Contests (CCCC) on qualifying cases. Please confirm the transmittal and credit with your partners.
18
Does this transmittal have an official VIP Enrollment Director Processing this?* This field is required.Your Enrollment Director send you your deduction report along with Benefit Summary Letters for Next year's open enrollment based upon the folks entered in THIS enrollment better preparing you for Next year!
Yes
No
19
Enrollment Director's Name* This field is required.Select from the Dropdown Menu Below
Please Select
Please Select
David Goddard
20
Who are your Executive Partner(s)? They will receive a notification of this transmittal in case they need to help you with processing this.* This field is required.
CO/CA - Alex Sell/Treve Rasmussen
AZ - Denise Forconi/Brendan Fox
OH - Susan Svarda
TX/OK/AR - Zach Milwood/Rick McKinney
21
DOES THIS NEW CASE QUALIFY FOR CASE RACE ENTRY? DOES IT HAVE AT LEAST 8 POLICIES ISSUED ON THIS FIRST TRANSMITTAL* This field is required.It's a NEW CASE and has AT LEAST 8 POLICIES ISSUED ON THIS TRANSMITTAL?
YESNO
22
Contest Integrity Statement* This field is required.
By checking this box, I acknowledge that all statements, credits, splits, annualized premiums, and account statuses on this transmittal are truthful and verifiable regarding splits, contests, and promotions.
Should be Empty: