AMERITAS Completed Case Spreadsheet and Transmittal Upload

Group/Account Name
Agent's Name

First NameLast Name
Agent's Email Address
example@example.com
Confirm the Requested Effective date of this enrollment

MonthDayYear
Date
Are you splitting commissions on this case with anyone else?
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%
Select ALL Products that you are transmitting
DENTAL RATES USED
VISION RATES USED
Please select your Executive Partner(s) for referencing
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!
Upload your Completed AMERITAS Census Enrollment here:

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