NEW CASE QUOTE REQUEST 2025

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Today's Date* This field is required.
Date
Month
Day
Year
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CASE STATUS?* This field is required.
BRAND NEW CASE - Never been built before
EXISTING CASE - CHANGING/MODIFYING PLANS
EXISTING CASE - NO POLICY CHANGES, UPDATING the ExpressEnroll Platform Only for efficiency.
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What Enrollment Platform will you be using* This field is required.If you are NOT using ExpressEnroll, YOU are responsible for the coordination and build directly with the carriers you select.
VIP's ExpressEnroll Enrollment Tool
Other Platform (like Employee Navigator
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What changes/additional plans are being placed? * This field is required.This helps your case builder ensure you have the latest enrollment version and let's the carrier know that changes are coming. Please be specific.
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YOUR (Agent/Partner) INFORMATION* This field is required.THIS IS NOT YOUR PROSPECT'S INFORMATION, BUT YOURS
YOUR NAME
Please enter your email (IF YOU HAVE A VIP EMAIL ADDRESS INSERT IT HERE)
Please enter your phone
Please Select
Please Select
FOUNDER'S CIRCLE MEMBER - PARTNER (front of the line)
PARTNER with VIP
VALUED BROKER that works with VIP
Affiliate
PLEASE SELECT YOUR STATUS WITH VIP
Please Select
Please Select
CO/CA/MO - Alex Sell/Treve Rasmussen
OH/LA - Susan Svarda
TX/AR/OK - Zach Milwood/Rick McKinney
AZ - Denise Forconi
TN/FL - Alfred and Karen Rietkerk
WHO IS YOUR EXECUTIVE PARTNER?
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CLIENT/PROSPECT INFORMATION* This field is required.PART 1
COMPANY/GROUP NAME
Yes
Please Select
Yes
No
Has this group been in business for over 1 year?
How many benefits eligible employees do they have? - (3+ GUARANTEE ISSUE*)
Please Select
Please Select
YES
NO
Do you have a picture or Logo of theirs that you can upload for their ExpressEnroll customization?
Nature of their business. BE SPECIFIC
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CLIENT/PROSPECT INFORMATION* This field is required.PART 2
Street Address (no PO Boxes)
City, Sate, Zip
Decision Maker's Name
Decision Maker's email address
Company/Group Phone Number
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Upload your Prospect's Logo Here for your Case Builder
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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CLICK NEXT TO REVIEW AND ACKNOWLEDGE THE SPECIAL UNDERWRITING AND MINIMUM ENROLLMENT/EDUCATION CONDITION STANDARDS THAT YOU HAVE AVAILABLE THROUGH VIP.
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For Groups with 3-249 employees:

SCROLL and READ THROUGH COMPLETELY BEFORE MOVING FORWARD

PLEASE REVIEW OUR BeneList Packages, underwriting Standards, Referral Opportunities and choose your offerings:

Our agency business will be reviewed quarterly to ensure our block of business meets Assurity's overall participation requirements of at least 15%. If VIP fails to meet acceptable participation guidelines, Assurity reserves the right to revoke or modify our underwriting offer, or reject any group, at any time.

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ASSURITY (groups with 3-249):

Assurity Accident - (2 apps required, Guarantee Issue, 90% EDUCATION and your due diligence is required)

Assurity Hospital w CI/Cancer - (2 apps required, Guarantee Issue, Waiver of Pre-Existing Conditions for ALL employees at initial enrollment and new hires, 90% EDUCATION and your due diligence is required)

Assurity Lump Sum CI/Cancer - (2 apps required, Guarantee Issue, Waiver of Pre-Existing Conditions for ALL employees at initial enrollment and new hires, 90% EDUCATION and your due diligence is required)

Assurity Disability - (2 apps required, Guarantee Issue) (Waiver of Pre-Ex available on TAKEOVER ONLY with a 6% load)

Assurity GROUP TERM LIFE - (Groups 3-9) - Minimum participation requirement of 3 applications. Always simplified issue up to $50,000.

Assurity GROUP TERM LIFE - (Groups 10-249) - (The greater of 5 apps or 10% of the employee count on the Master App required, Guarantee Issue up to 100k!)

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DENTAL/VISION PACKAGE (groups with 3-249)

Beam Dental/Vision 3-50 lives (Your State's Shelf Rates - 2 apps required)

Beam Dental/Vision 50+ lives (Custom Rates are required - 2 apps required)

BEAM EMPLOYER PAID LIFE (optional) (25 or 50k, Census required - not voluntary)

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VIRTUAL HEALTH PACKAGE (Choose ONE)

LYRIC TELEHEALTH & EAP w GoLexi Virtual Pet Health- $12/PEPM (2 minimum requirement)

or

LYRIC COMPLETE VIRTUAL PRIMARY CARE, $0 Copay Acute Prescriptions, Virtual Urgent Care, Wellness Labs, Virtual Urgent Care, EAP, and GoLexi Virtual Pet Health - $65/PEPM (2 minimum requirement)

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PERMANENT LIFE (Groups with 5+)

5Star Life Term to age 121 with LIVING BENEFITS for LTC Needs - (5 min enrolled requirement, Guarantee Issue up to 100k!)

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ICHRA/CHOICE MEDICAL INSURANCE REFERRAL

ATMA PMF - will Handle everything for your client regarding ICHRA/CHOICE Medical Plans. THIS IS the future of group Medical Insurance. Believe this. Group Major Medical Brokers have shifted 40% of the market in the last 3 years to ICHRA/CHOICE. Work with a broker that will actually help you place Hospital Indemnity in EVERY CASE for you!

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JBA WEALTH MANAGEMENT/HUMAN INTEREST 401k REFERRAL

HUMAN INTEREST 401K is the EASY BUTTON to offer affordable 401k Solutions to your client! $100 for a set appointment from them and another $300 for a closed referral!

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RED RIVER PAYROLL& HR SOLUTIONS REFERRAL

RED RIVER PAYROLL Can relieve the HR and Payroll headaches for your clients. Stay sticky without letting the fox in your henhouse!
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For Groups with 250+ employees:

SCROLL and READ THROUGH COMPLETELY BEFORE MOVING FORWARD

PLEASE REVIEW OUR BeneList Packages, underwriting Standards, Referral Opportunities and choose your offerings:

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Assurity Accident - Custom Underwriting approval required

Assurity Hospital w CI/Cancer - Custom Underwriting approval required

Assurity Disability - Custom Underwriting approval required

Assurity GROUP TERM LIFE - Custom Underwriting approval required

Assurity Lump Sum CI/Cancer - Custom Underwriting approval required

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Beam Dental - (CUSTOM RATE QUOTES REQUIRED - 2 apps required)

Beam VSP Vision - (CUSTOM RATE QUOTES REQUIRED - 2 apps required)

BEAM EMPLOYER PAID LIFE - (25 or 50k, Census required - not voluntary)

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LYRIC TELEHEALTH & EAP w GoLexi Virtual Pet Health- $12/PEPM (2 minimum requirement)

or

LYRIC COMPLETE VIRTUAL PRIMARY CARE, $0 Copay Acute Prescriptions, Virtual Urgent Care, Wellness Labs, Virtual Urgent Care, EAP, and GoLexi Virtual Pet Health - $65/PEPM (2 minimum requirement)

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5Star Life Term to age 121 w Living Benefits - (15% enrolled requirement, Guarantee Issue)

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ICHRA/CHOICE MEDICAL INSURANCE REFERRAL

ATMA PMF - will Handle everything for your client regarding ICHRA/CHOICE Medical Plans. THIS IS the future of group Medical Insurance. Believe this. Group Major Medical Brokers have shifted 40% of the market in the last 3 years to ICHRA/CHOICE. Work with a broker that will actually help you place Hospital Indemnity in EVERY CASE for you!

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HUMAN INTEREST 401k REFERRAL

HUMAN INTEREST 401K - is the EASY BUTTON to offer affordable 401k Solutions to your client! $100 for a set appointment from them and another $300 for a closed referral!

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RED RIVER PAYROLL& HR SOLUTIONS REFERRAL

RED RIVER PAYROLL - Can relieve the HR and Payroll headaches for your clients. Stay sticky without letting the fox in your henhouse!
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100+ Life Acknowledgement* This field is required.By initialing I acknowledge that VIP requires that 10% of the group size on every LOB offered and 15% of the group size is required for Life Insurance. I understand that in order to protect our underwriting, VIP reserves the right to turn down any enrollment below this minimum standard.
Clear
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Do you need your enrollment to reflect a payroll cycle other than Monthly?* This field is required.All.proposals will be built monthly so invoicing is correct on the backend.
Weekly (52)
Biweekly (26)
Semi-Monthly (24)
Monthly (12) is just fine
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Do you need a Spanish link as well for this case?* This field is required.
English Only Please
Sí, tengo mucha gente que habla español en esta cuenta.
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MARK ALL Products that apply (Must have at least 10 employees to offer Term Life)* This field is required.
Assurity Accident
Assurity Hospital w CI/Cancer
Assurity Disability
Assurity Group Term Life*
Assurity Lump-Sum Critical Illness/Cancer
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Disability Benefit Periods and Elimination Periods to offer* This field is required.We STRONGLY recommend only offering one elimination and one benefit period - Less is MORE.
13 Week Benefit Period
0/7 Elimination Period
26 Week Benefit Period
0/14 Elimination Period
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DENTAL/VISION PACKAGE PRODUCTS TO INCLUDE* This field is required.Unless in a competitive situation please use Shelf Rates in cases sized 3-49. This helps keep our renewal increases lower in the long haul. We currently have a 2 year rate lock with a 5% cap.
BEAM DENTAL/Vision - 3-49 lives (shelf rates)
BEAM DENTAL/Vision 50+ lives (Custom Quote)
Beam Dental/Vision (Competitive Takeover - Custom Quote) - You will need to upload their current offer/census/invoice
Beam Employer Paid Life 25k
Beam employer Paid Life 50k
I am not offering a Dental/Vision Package
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VIRTUAL HEALTH PACKAGE PRODUCTS TO INCLUDE* This field is required.
LYRIC BASIC - TELEHEALTH & EAP + Go Lexi Vet Telehealth ($12/PEPM)
LYRIC COMPLETE - VIRTUAL PRIMARY CARE ++++ ($65/PEPM)
I am not offering any Virtual Health Care Packages
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LIFE EVENT PACKAGE PRODUCTS TO INCLUDE* This field is required.
5 Star Life - Term to age 121 w Living Benefits
I am not offering any of the Life Event Package Products
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REFERRAL NOTIFICATIONS* This field is required.Please mark all referrals that you intend to send. We will email you the links for the referral forms that are required.
ICHRA/CHOICE - Medical Insurance that Employers can afford!
HUMAN INTEREST 401k/JBA Wealth Management
Red River Payroll/HR Solutions
I am not referring any of these services out
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Assurity DISABILITY TAKEOVER - Credit for time insured/waiver of Pre-Ex* This field is required.THIS IS for disability TAKEOVERS only. You MUST provide a CURRENT and up to date invoice with all current disability policyholders. We already have a Waiver of Pre-Ex included for Hospital and Critical Illness.
I need a Waiver of Pre-Ex for Disability (There is a 6% load on the Disability Premiums for this)
This is a fresh case with no Waiver of Pre-Ex needed for Disability
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Takeover Acknowledgement* This field is required.By initialing I acknowledge that this is a TAKEOVER and NOT a Coexistence. I understand that this is an underwriting privilege that I have through VIP, and I will maintain the highest ethical standards.
Clear
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What carrier are you taking over?* This field is required.
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Upload the Current Invoice Here:This is required for a takeover and waiver of existing policyholder's pre-existing conditions
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
If you do not have this right now, be sure and get this to your case builder BEFORE your enrollment.
Cancelof
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Are there ANY special notes that were not covered in this form that you need to let our Carriers, Vendors, Referral Partners, and Case builder's know? This is your place to communicate.
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