BEAM SOLD CASE NOTIFICATION

Group Name*
Effective Date of the Dental plan*

MonthDayYear
Date
Number of eligible employees*
Nature of their Business*
Group Zip Code*

Street Address

Street Address Line 2

City

Zip Code
Agent Name*

First NameLast Name
Agent Email
example@example.com
Select ALL Sold Products that apply to this case:*

DentalVisionER Paid Life $25kER Paid Life $50k
Would you like to have your VIP Enrollment Director complete the data input, submissions, deduction reports and complete your Transmittals? They will send the deduction report directly to you once the transmittal is complete. This makes life MUCH easier.*

Yes! I want my Enrollment Director to do the back-end work for me. I just want to open cases, enroll, kick backside and cash mad checks!No thanks, I'll manually input all my data and prep my own deduction reports and send my own transmittal. I am responsible for getting this done in a timely fashion.
Is this case a custom quoted case or Standard Shelf rates?*
Who is/are your Executive Partner(s) to receive this notice. *
Hey there!

I have sold this case.

Please send me the IMPLEMENTATION EMAIL to complete.

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DENTAL:

Voluntary MAC 100/80/50/0 in and out of network.

50/150 deductible.

$2000 max.

endo/perio in BASIC.

sealants/space main in prev.

imp/alt; no wp’s

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VISION:

Voluntary - VSP 3

Thank you!
Should be Empty: