Case Build Request Company Name * Street Address * Street Address Line 2 City * State/Province * Postal/Zip Code * Country * —Please choose an option—United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRepublic of the CongoRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSouth SudanSpainSri LankaSudanSurinameSvalbardeSwatiniSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsIsle of ManUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Contact Info Contact Name Phone Email Business HR Contact - Primary Business Contact Info - Secondary Broker Contact Info - Primary Broker Contact Info - Secondary Name of Brokerage Enrollment Dates Start Date of Enrollment * Plan Effective Date * Business Basics Type of Business Tax ID # of Employees Number of Benefit Classes Number of Locations Payroll Cycle WeeklyBi-WeeklySemi-MonthlyMonthly Reporting Info - Required Info for Reporting Locations —Please choose an option—YesNo Other —Please choose an option—YesNo * Please note that if locations, job titles or any other info is required for reporting, then they need to be on the census at time of submission. Company Logo Employee Classes If all employees are considered to be part of the same class, then only “Class 1” needs to be completed. Class Name Number of Pay Cycles Waiting Period Benefits Eligibility Class 1 Class 2 Class 3 Date of First Payroll After Effective Date * Date of Second Payroll After Effective Date * Please select the plans below that are being offered: Check the Plans Being Offered Name of Carrier Number of Plans Pretax (Check if Yes) Medical Yes Yes Dental Yes Yes Vision Yes Yes Basic Life Yes Yes Voluntary Life Yes Yes Short Term Disability Yes Yes Long Term Disability Yes Yes Notes on Classes and Product Offerings: How will Open Enrollment be Conducted? Check all that apply: Face-to-FaceTelephonicSelf-Service EDI Needed (Additional Costs May Apply) YesNo Medical Medical Plan 1: Name Medical Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Medical Plan 1 Rates (Just Need Employer OR Employee Contributions) Monthly Rate Monthly Employer Contribution Employee Monthly Contribution Employee Employee/Spouse Employee/Child Employee/Children Family Medical Plan 2: Name Medical Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Medical Plan 2 Rates (Just Need Employer OR Employee Contributions) Monthly Rate Monthly Employer Contribution Employee Monthly Contribution Employee Employee/Spouse Employee/Child Employee/Children Family Medical Plan 3: Name Medical Plan 3: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Medical Plan 3 Rates (Just Need Employer OR Employee Contributions) Monthly Rate Monthly Employer Contribution Employee Monthly Contribution Employee Employee/Spouse Employee/Child Employee/Children Family Notes for Medical Plans: Dental Dental Plan 1: Name Dental Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Dental Plan 1 Rates (Just Need Employer OR Employee Contributions) Monthly Rate Monthly Employer Contribution Employee Monthly Contribution Employee Employee/Spouse Employee/Child Employee/Children Family Dental Plan 2: Name Dental Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Dental Plan 2 Rates (Just Need Employer OR Employee Contributions) Monthly Rate Monthly Employer Contribution Employee Monthly Contribution Employee Employee/Spouse Employee/Child Employee/Children Family Notes for Dental Plans: Vision Vision Plan 1: Name Vision Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Vision Plan 1 Rates (Just Need Employer OR Employee Contributions) Monthly Rate Monthly Employer Contribution Employee Monthly Contribution Employee Employee/Spouse Employee/Child Employee/Children Family [text vision-plan-3-family-monthly-employer-contribution [text vision-plan-3-family-employee-monthly-contribution] Vision Plan 2: Name Vision Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Vision Plan 2 Rates (Just Need Employer OR Employee Contributions) Monthly Rate Monthly Employer Contribution Employee Monthly Contribution Employee Employee/Spouse Employee/Child Employee/Children Family [text vision-plan-2-family-monthly-employer-contribution [text vision-plan-2-family-employee-monthly-contribution] Notes for Vision Plans: Disability Rates Short Term Disability Short Term Disability Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Short Term Disability Employer Paid STD Details % of Weekly Earnings Rounding Type —Please choose an option—Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000 Rounding To —Please choose an option—Up Minimum Benefit Maximum Benefit Waiting Period Benefit Period Short Term Disability Monthly Rate per $10 of Benefit Employee Monthly Rate 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-plus Short Term Disability Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Short Term Disability Employer Paid Notes for Short Term Disability: Long Term Disability Long Term Disability Plan 1: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Long Term Disability Employer Paid LTD Details % of Monthlyly Earnings Rounding Type —Please choose an option—Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000 Rounding To —Please choose an option—Up Minimum Benefit Maximum Benefit Waiting Period Benefit Period Long Term Rates will be: —Please choose an option—Per $100 of Covered PayrollPer $100 of Benefit Employee Monthly Rate 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-plus Long Term Disability Plan 2: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Long Term Disability Employer Paid LTD Details % of Monthly Earnings Rounding Type —Please choose an option—Nearest .01Nearest .10Nearest $1Nearest $10Nearest $100Nearest $1,000 Rounding To —Please choose an option—Up Minimum Benefit Maximum Benefit Waiting Period Benefit Period Long Term Rates will be: —Please choose an option—Per $100 of Covered PayrollPer $100 of Benefit Employee Monthly Rate 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Notes for Long Term Disability: Life Rates Basic Life Basic Life: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Basic Life Employer Paid Benefit Amount: Monthly Rate per $1000 of Benefit 18-24 25-29 30-34 35-39 40-44 45-49 [text [text basic-life-45-49-monthly-rate-per-1000-dollars-of-benefit] 50-54 55-59 [text [text basic-life-55-59-monthly-rate-per-1000-dollars-of-benefit] 60-64 65-69 70-74 75-plus Age Reduction Starting Age Ending Age % Reduced By Notes on Basic Life: Voluntary Life Voluntary Life: Which Classes are eligible for this plan? AllClass 1Class 2Class 3 Basic Life Monthly Rate per $1000 of Benefit (include AD&D rate with Basic Life if applicable) Benefit Amount Limits Minimum Benefit Amount Maximum Benefit Amount Multiple of Salary Limit % of Employee Election Employee Spouse Dependents Dependent Eligibility Minimum Dependent Age Maximum Dependent Age Maximum Student Age Guarantee Issue Limits Initial Open Enrollment/New Hires Late Entrants/Did Not Sign Up Initially Existing Enrollment/Increasing Coverage Employee Spouse Employee Life Rate Rules Spouse Rates Match Employee? —Please choose an option—YesNo Dependents Rates Based on Age of Employee? —Please choose an option—YesNo Life and AD&D Combined? —Please choose an option—YesNo Rates Based on Tobacco Use? —Please choose an option—YesNo ######### When age-band changes, update rates on —Please choose an option—First Month FollowingPolicy AnniversaryBirthday When age reductions occur, reduce benefits on —Please choose an option—First Month FollowingPolicy AnniversaryBirthday When age-band changes, reduce benefits on —Please choose an option—First Month FollowingPolicy AnniversaryBirthday When age reductions occur, reduce benefits on —Please choose an option—First Month FollowingPolicy AnniversaryBirthday Voluntary Life Monthly Rate per $1000 of Benefit Employee Spouse Tobacco Employee Tobacco Spouse 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ Age Reduction Starting Age Ending Age % Reduced By Dependent Rate per $1,000 Notes on Voluntary Life: FSA, HSA, HRA Being Offered Employer Contribution FSA Yes HSA Yes HRA Yes Δ
