• New Case Quote & ExpressEnroll Platform Request

    Please fill out and submit this form to get your requested proposal(s) and case built for you in ExpressEnroll if requested. All cases start here!
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • CASE STATUS?*
  • What Enrollment Platform will you be using*
  • Your Status with VIP*
  • Partner Lookup
  • Format: (000) 000-0000.
  • Who is your Executive Partner?*
  • Are you working this case with additional agents who need to be included on communications?*
  • Who do you want to run point on your case for Voluntary Benefits?*

  • Company/Group Information

  • Has this group been in business for over 6 months?*
  • Format: (000) 000-0000.
  • Do you have a logo you can upload for ExpressEnroll customization?*
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  • Case Build Options

  • Do you need your enrollment to reflect a payroll cycle other than Monthly?*
  • Do you need a Spanish link as well for this case?*
  • Is this a Spanish Speaking OWNED business where the decision maker would prefer a Spanish Assurity Proposal along with English? (This is am EMPLOYER proposal and is not given to employees - ExpressEnroll and Spanish brochures are available in Spanish for employees)
  • MARK ALL Assurity Products that apply

  • Please review your product minimum requirements below from what you selected, and be sure to use due diligence in ensuring that you have enough enrollment for the line of business that you selected. Remember, enrollment conditions and education conditions mean everything. Do not be afraid to pull back product if the minimums cannot be met.

  • Assurity Accident

    • 2 applications required
    • Guarantee issue

  • Assurity Hospital with CI/Cancer

    • 2 applications required
    • Guarantee issue
    • Waiver of pre-existing conditions for ALL employees at initial enrollment and new hires

  • Assurity Lump Sum Critical Illness/Cancer

    • 2 applications required
    • Guarantee issue
    • Waiver of pre-existing conditions for ALL employees at initial enrollment and NEW HIRES

  • Assurity Group Term Life

    • The greater of 5 applications or 10% of the employee count on the Master Application
    • Guarantee Issue A150,000mounts
      • 3-9 lives: $25,000
      • 10-99 lives: $100,000
      • 100+ lives: $150,000

  • Assurity Short Term Disability

    • 2 applications required
    • Guarantee issue
    • Waiver of pre-existing conditions available on TAKEOVER cases only with a 6% load on rates (current carrier invoice required to be uploaded) and new hires
  • Disability Benefit Periods and Elimination Periods to offer*
  • Assurity DISABILITY TAKEOVER - Credit for time insured/waiver of Pre-Ex*
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  • AMERITAS PRODUCTS TO INCLUDE*

  • This group qualifies for shelf rates for Ameritas Dental/Vision.  No further action is needed on your part - your casebuilders will use the shelf rates when building your case!

  • Amertias shelf rates are not available for this group's state.  Please upload an employee census below so Ameritas can send you custom rates.

  • This group is larger than 200 lives and requires a custom quote from Ameritas.

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  • VIRTUAL HEALTH PACKAGE PRODUCTS TO INCLUDE*
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  • YOU WILL NOW BE REDIRECTED TO REQUEST YOUR BOSTON MUTUAL PRODUCTS

     

    If you require a quote for other carriers, please complete the Boston Mutual request now.

    There is an option to be taken back here once your request has been submitted.

     

    Please proceed below:

  • When you hit "Submit" you will be redirected to the Case Build Update Request Form

  • Should be Empty: