New Case Checklist

Business Name *

PA First Name *

PA Last Name

Phone *

Email *

Opener *

BCN *

Tax ID# *

Employer Contribution *

Case Build Plan Details *

Case Build Platform *

Case Build Type *

Eligibility - Minimum hours worked per week *

Domestic Partners *

Frequency for Payroll *

Enrollment Start Date *

Enrollment End Date *

Target Effective Date *

Employee Education Date *

Enrollment Type *

How many enrollers do you need? *

How many bi-lingual enrollers do you need? *

How will you submit the Core Benefit Information? *

Account Information Form (AIF)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

FLEX Form

PDF

GMAPP

PDF

Quick Quote

PDF

CORE RATE SHEET

PDF

BENEFIT BOOKLET

PDF

EMPLOYEE CENSUS

XLSX, XLS or CSV

Notes

Please do let the Coordinator know when deductions need to be sent and to who

Bolt - GHL Resources Requested (check all that apply)

None

One Pager

Landing Page

Bolt - GHL Communications Campaign Requested (check all that apply)

None

Ringless VM, Email and Text - Single Reach Out Campaign

Email and Text - Single Reach Out Campaign

Email and Text - Multi Day Campaign

Text Only - Single Reach Out Campaign

Ringless VM, Email and Text - Multi Day Campaign

By checking this box, I consent to receive non-marketing text messages from [BUSINESS NAME] about [USE_CASE_FROM_CAMPAIGN_DESCRIPTION]. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from [BUSINESS NAME] at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Privacy Policy | Terms of Service

New Case Checklist

**Please do let the Coordinator know when deductions need to be sent and to who**

Please do let the Coordinator know when deductions need to be sent and to who