Completed Electronic Enrollment Case Setup Workbook

Electronic Enrollment Case Set-Up Workbook for Assurity's Business Transformation Department

This form let's the BT department know how to build your enrollment in BenSelect (Selerix). By inputting your enrollment information into Selerix, we can maintain weekly EDI feeds to Assurity. All employee updates, changes, and new hires can be transmitted weekly through this system!
Agent 1 Name*
Agent 2 Name (if applicable)
Who built your ExpressEnroll Link for you so they are notified that this form is complete? *
Are you using your Enrollment Director (David Goddard) to handle the implementation with our carriers, create benefits summary letters, and give you the deduction reports for this case? This would include all other carriers in addition to Assurity.*

Yep. I am here to sell... not get bogged down with administrative work.Nope. I like David, but I can't let go.
Completed Electronic Enrollment Case Setup Workbook
Agent 1 Phone Number*
Agent 1 Email Address*
example@example.com
Company/GROUP Legal Name*
Group Contact Name*

First NameLast Name
Group Contact Phone*
Group Contact Email Address*
Group Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Situs State (Where their home office is)*
Assurity Products to be built in BenSelect*

AccidentDisabilityCI/CancerHospital (with CI/Cancer)Group TERM Life (100 or 150k GI)3/6/9 WHOLE Life
Please mark ALL other products that you have in this case for David Goddard.*

There are no other offerings... just Assurity.Beam DentalBeam Vision5Star Life Term to age 121Lyric Telehealth (Basic)Lyric VPC (Complete)Sedera Healthshare
Does Beam Dental/Vison have SHELF rates or Custom Rates?*

Shelf (Easy Peasy)Custom Rates
Important. We set things up with Assurity as MONTHLY so the invoicing is correct every month. (A calendar doesn't always fit into a calculator.) David can send you a deduction report that fits with your case's actual payroll cycle. Please select how you would like that deduction report to show.*

Weekly (52)BiWeekly (26)Semi-Monthly (24)Monthly (12)
Is this a Takeover Case where you needed a Waiver of Pre-Ex on Disability with the 6% load on the premiums? Waiver of Pre-Ex for Hospital and Critical Illness/Cancer is already applied to the whole case as of 3/12/2025.*

Yes - You have the Invoice and it has been uploaded and sent to Assurity.No - This is NOT a takeover but a fresh case
Enrollment Start Date*

MonthDayYear
Date
WRITING AGENT: IMPORTANT INFORMATION! PLEASE READ and SELECT CAREFULLY

Business Transformation will SHUT DOWN the availablility to enroll this after the date that you select for the enrollment end date below (this eliminates possible adverse selection).

To prevent unnecessary back and forth emails and reopening of BenSelect... give yourself a little leeway here.
Enrollment End Date (Set this date to be a few days AFTER you are actually done with ExpressEnroll so BT doesn't close your case too early for administration of your applicants) - ie: If your Education/ExpressEnroll actually ends on 09/05/2025... use a date like 09/09/2025. *

MonthDayYear
Date
Policy Effective Date*

MonthDayYear
1st of the following month is recommended
Payroll Frequency*

BiWeekly (26)Semi-Monthly (24)Weekly (52)Monthly (12)
Are there employer locations that require separate benefits, tracking, or billing departments?*

YesNo
If "yes" list desired location names and physical city, state below and any specifics that apply*
AFTER SUBMITTING - YOU WILL BE REDIRECTED TO A SHORT FORM THAT WILL GO TO YOUR ENROLLMENT DIRECTOR. PLEASE FILL IT OUT SO THEY CAN WORK FOR YOU. THANKS!
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Electronic Enrollment Case Set-Up Workbook for Assurity's Business Transformation Department

Completed Electronic Enrollment Case Setup Workbook