5 STAR LIFE CASE SET-UP FORM

5 STAR LIFE CASE SET-UP FORM
Employer/Group Name*
Employer/Group Address*
Employer/Group Situs State*
Nature of Business/SIC Code
Tax ID
Total Number of Eligible Lives
Billing Contact
Group/Business Contact Phone

Area CodePhone Number
Group/Business Contact E-mail
example@example.com
Mark ALL policies to be offered*

LifeAccidentHospital Indemnity
Enrollment Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Requested Effective Date

MonthDayYear
Date
First Bill Date

MonthDayYear
Date
First Deduction Date

MonthDayYear
Date
Servicing Agent/Agency Name
AGENT WHO IS OPENING THE CASE
Servicing Agent's Email*
example@example.com
Servicing/Opening Agent Writing # (Dan Ealy sent you an email with your writing #)
Premium Split Information This section must be received before applications can be processed: Agent Number and Premium Split Percentage. (Split must equal 100%)
Are you letting your Enrollment Director handle everything on the back end? - If you are using an enrollment director... then answer is "yes". David's writing number is CC026HMA
Writing Agent#1 Name

First NameLast Name
Agent 1 Split Percentage (Put 100 if it's just you - Put in 90% for yourself if you are using David Goddard as your Enrollment Director)
Agent 2 Name - (Include 10% to David Goddard if using your Enrollment Director - CC026HMA)
Agent 2 Agent # (David Goddard's Writing # is CC026HMA)
Agent 2 Split Percentage
Agent 3 Name
Agent 3 Agent #
Agent 3 Split Percentage
Agent 4 Name
Agent 4 Agent #
Agent 4 Split Percentage
Should be Empty: