FECN

1
Today's Date* This field is required.
Date
Month
Day
Year
2
Preliminary Information* This field is required.
Account/Company/Group Name
Your Name
Your email
Your phone
3
Type of Enrollment you just FINISHED and COMPLETED.* This field is required.
This is a NEW CASE
This is an EXISTING CASE, Open Enrollment
This is a NEW HIRE(S) Enrollment
4
Have you taken into account your waiting period that you have set up with your case based upon the hire dates to ensure GUARANTEED ISSUE and this will not be considered a late entry and become simplified issue? Edit your hire dates if needed but DO NOT conduct adverse selection!
YESNO
5
What Days did you enroll this group?* This field is required.Everyone that is in your google sheet on or between these dates will be entered.
Date you Started this Enrollment
Date you FINISHED this enrollment
6
Are you a VIP Founder's Circle Member? * This field is required.Founder's Circle Members are placed in the front of the queue.
YESNO
7
Effective Date for this Enrollment* This field is required.The effective date MUST be after today's date
Date
Month
Day
Year
8
Hi {yourInformation[1]} .

Unfortunately we cannot process this for a {effectiveDate} enrollment unless special arrangements/concessions with your enrollment director have already been made.

You will need to change the effective date to the first of the next month with this account. We need put pressure on SYSTEMS and not people. Following the systems in place will always help ensure an effective and more accurate enrollment.

If Special accomodations/or concessions have been made and agreed upon already go ahead and hit next.

If not, we ask that you not proceed with this notification until the effective date has been changed with each carrier. Also BenSelect and your NEW MASTER APPs must reconfigured and reopened to the corrected effective date.

Thank you!

- VIP Ledership Team
9
Is your ExpressEnroll Enrollment COMPLETE and FINISHED for all carriers and has your enrollment concluded?* This field is required.We do not go back and add random late entries. Late entries are SIMPLIFIED ISSUE and lose Guarantee Issue privileges to protect our underwriting.
YESNO
10
Have you gone through your Google Sheet? Have edited and/or verified that all the information in your Google Sheet is CORRECT and IN ORDER? Can you verify that no columns are hidden and the columns are in the exact same format in which you received? Are ALL Hire Dates and Birth Dates are correct? Are the State and City Spellings and abbreviations are correct? * This field is required.This is EXTREMELY important.
YESNO
11
Have you confirmed that your case has been built in Assurity's BenSelect system and is good to go?* This field is required.This is EXTREMELY important.
YESNO
12
Hey {yourInformation[1]} .

It's extremely important that the following is complete at a minimum:

1. That your enrollment is COMPLETE and FINISHED. Late entries get simplified issue (not guarantee issue) and are subject to Statements of Health.

2. You have gone through your Google Sheet and edited and/or verified that all the information in your Google Sheet is CORRECT and IN ORDER. You also must verify that no columns are hidden and the columns are in the exact same format in which you received from your Case bulder. Also make sure that ALL Hire Dates and Birth Dates are correct and the State and City Spellings and abbreviations are correct.

3. You have confirmed that your case was built in Assurity's BenSelect System.

PLEASE ensure ALL 3 of these items are completed. Failure to do so puts you at the rear of the queue.
13
Mark ALL carriers that are offered in this case for your enrollment director to handle for you* This field is required.
Assurity
Beam
5Star Life
Lyric
14
Please Mark ALL applicable policies offered in this enrollment* This field is required.
Assurity Accident
Assurity Disability
Assurity Hospital Indemnity
Assurity Life (Term or Whole)
Assurity Lump-Sum Critical Illness
5Star Term to 121
5Star Accident
5Star Hospital
Lyric Basic Telehealth
Lyric Complete VPC
Beam Dental - SHELF RATES
Beam Dental - CUSTOM RATES
Beam Vision - SHELF RATES
Beam Vision - CUSTOM RATES
Beam ER Paid Life
15
Are ALL of the group's employees on your Google Sheet for the Beam ER Paid Life? * This field is required.This is a census enrollment and not a voluntary product. The entire census needs to be available for this product.
YESNO
16
Is this a NEW enrollment or an existing account's open enrollment?* This field is required.
NEW CASE baby!
Stayin' sticky with my cases! Existing and long-term account of mine.
17
Are there any existing policyholders in this account that have made changes that you are aware of (adding coverages/family changes/etc) * This field is required.Please list them all below. This is a HUGE help in getting your business processed.
Huge
Large
Normal
Small
Ok
Ok
18
Are there any NEW PRODUCTS being offered in this open enrollment that were not offered before?* This field is required.Please list all NEW/ADDED products to this enrollment below.
Huge
Large
Normal
Small
Ok
Ok
19
Please Copy/Paste your Google Sheet URL here:
Huge
Large
Normal
Small
Ok
Ok
20
What Payroll Cycle should your Deduction Report Reflect?* This field is required.
Monthly (12)
Semi-Monthly (24)
BiWeekly (26)
Weekly (52)
21
Please add all partners/brokers or anyone with commission splits AND their percentages for them to receive INCLUDING YOURSELF. Totals must equate to 95%. Your enrollment director will receive a 5% transmittal as a default.
Agent #1 (the account goes in this person's name
Agent #2
Agent #3
Agent #4
22
Are there ANY special instructions that you wish to give to your Enrollment Director? - If not, please leave this blank. ie: Multiple Paycycles/Departments or special circumstances?
Huge
Large
Normal
Small
Ok
Ok
23
Select your Executive Partner
Alex Sell
Brendan Fox/Denise Forconi
Susan Svarda
Zach Milwood
Rick McKinney
Should be Empty: