Beam Completed Case Spreadsheet and Transmittal

1

Group/Account Name* This field is required.

2

Agent's Name* This field is required.

First Name

Last Name

3

Agent's Email Address* This field is required.

example@example.com

4

Confirm the Requested Effective date of this enrollment* This field is required.

Date

5

Are you splitting commissions on this case with anyone else?* This field is required.

Yes

No - I have 100% of the commissions on this case

6

If you are splitting commissions, please indicate their names, emails, and percentage of all splits below. Include yourself in this list and all commissions must total 100%

7

Select ALL Products that you are transmitting* This field is required.

Dental

Vision

ER Paid Life $25k

ER Paid Life $50k

8

DENTAL RATES USED* This field is required.

Shelf

Case specific quoted

9

VISION RATES USED* This field is required.

Shelf

Case specific quoted

10

Please select your Executive Partner(s) for referencing

Alfred and Karen Rietkerk TN/FL/SC

Alex Sell/Treve Rasmussen CA/CO/MO

Susan Svarda OH

Zach Milwood/Rick McKinney TX/AR/OK

Denise Forconi AZ

11

Hello!

I have completed the enrollment for this group. The spreadsheet is uploaded in this form. Please process. I am the point of contact if there are any issues that are needed and please feel free to reach out to me.

Thanks!

12

Upload your Completed Beam Census Enrollment here:* This field is required.

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