Assurity GROUP Worksite Pended Business Communication
This form will go to the Worksite New Business Department, Business Transformation, and the Regional Sales Coordinator at Assurity so everyone can assist in your pended applications and making processes smoother for everyone who can help get your business issued. THIS FORM IS NOT TO BE USED FOR INDIVIDUAL ASSURITY PRODUCTS.
Agent's Name
*
First Name
Last Name
Agent's Email
*
example@example.com
What Assurity RSC primarily needs to see this?
*
Please Select
Zach Williams - AZ/CA
Taylor Pederson - CO/UT/MO
Joe Stegman - TX/OK/TN
Rachel Vandermuss - OH/IN
How many applicants do you have IN THIS SAME GROUP that have the same pended issue that can be communicated in this same form?
*
Please Select
1
2
3
4
5
6
7
8
9
10
Group Name
*
#1 Applicant's Name
*
First Name
Last Name
#2 Applicant's Name
*
First Name
Last Name
#3 Applicant's Name
*
First Name
Last Name
#4 Applicant's Name
*
First Name
Last Name
#5 Applicant's Name
*
First Name
Last Name
#6 Applicant's Name
*
First Name
Last Name
#7 Applicant's Name
*
First Name
Last Name
#8 Applicant's Name
*
First Name
Last Name
#9 Applicant's Name
*
First Name
Last Name
#10 Applicant's Name
*
First Name
Last Name
Has the applicant of this pending application successfully submitted an exceptional Statement of Health? We would like to inform all concerned parties that the document has been completed and kindly request its prompt processing.
*
Yes
No
Have the needed requirements given to you on the Pended Business Report which you received from Assurity via email been satisfied?
*
Yes
No
If there is any additional information regarding this pending application that BT, WNB, and the RSCs need to be aware of or that you would like to convey to them, please provide your communication here:
Our VIP SOH systems will directly send a completed SOH to Worksite New Business when they submit their form if you sent them the SOH link. You can upload any additional supporting documents here.
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