5Star Life Completed Enrollment Notification and Spreadsheet Transmittal

1
Congratulations on successfully completing your 5Star Life Enrollment on your case!

To proceed, please upload your completed 5Star Census and submit securely in this form.

Additionally, please remember that YOU are responsible for your deduction report. We recommend using your Enrollment Director to handle all of this for you, or manually utilizing your census to create your own deduction report.
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Writing Agent's Name* This field is required.
First Name
Last Name
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Agent's Email* This field is required.
example@example.com
4
Was this case processed by David Goddard, our Enrollment Director? If so, David will get your deduction report to you and be responsible for timely issuance. He will receive a 10% transmittal split for his work. The Writing agent(s) will receive the remaining 90%* This field is required.
Yes
No, I did this myself.
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Agent's Phone Number* This field is required.
Area Code
Phone Number
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GROUP/COMPANY name enrolled* This field is required.
7
Date your enrollment was finished* This field is required.
Date
Month
Day
Year
8
Effective Date of these applications* This field is required.
Date
Month
Day
Year
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How many EMPLOYEE applications are on this spreadsheet? * This field is required.
10
Annualized Premium Being Transmitted* This field is required.
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What type of Enrollment is this?* This field is required.
New Account
Open Enrollment in an Existing Account
New Hires in an Existing Account
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Upload your Census or PDF applications here:* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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