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New & Existing Case Checklist
Agent Information
*
Indicates required field
Primary Agent Name (Case Count)
*
First
Last
Primary Agent Email
*
Primary Agent Phone Number
*
Primary Agent Code
*
Secondary Agent Name
*
First
Last
[object Object]
Secondary Agent Email
*
Secondary Agent Phone Number
*
Secondary Agent Code
*
Commission Split If Applicable
*
Not Applicable
75% Primary, 25% Secondary Agent
50% Primary, 50% Secondary Agent
25% Primary, 75% Secondary Agent
100% Primary
100% Secondary
Broker Name (If Appl.)
*
Broker Code (req. if Broker Name provided)
*
Commission Schedule (If Appl.)
*
DGA Last Name
*
ADM Last Name
*
Please enter the name of your District General Agent, "DGA".
New Case Information
Are we enrolling core products?
*
-
Yes - See (?) for more info.
No
If yes, please email the rates, SBCs and contribution strategy to
[email protected]
.
Account Name
*
Agent Code for Case Count
*
BCN
*
CAN
*
Risk Class
*
Coverage Effective Date
*
MM/DD/YYYY
Premium Effective Date
*
MM/DD/YYYY
Benefit Bank?
*
No
Yes - Leave Notes
Employer Paid?
*
No
Yes - Leaves Notes
Status of Employer Contribution Data Form
*
Not Applicable
Applicable, Completed (req. if "Yes" to Benefit Bank/Employer Paid)
Notes on Benefit Bank and/or Employer Paid
*
Pre-Enrollment: Opener Responsbilities
Fast Forms signed, Sent to Home Office and
[email protected]
?
*
Yes
Re-Work?
*
Yes
No
Opener Comp and Case Count listed on sheet?
*
Yes
No
ePOP, if Pre-Tax, sent to
[email protected]
?
*
Yes
Not Pre-Tax
If, "yes", Need Eligibility, Entity type & CORE products
Is Group Meeting date and time set?
*
Yes
No
Date & Time of Group Meeting
*
Additional Group Meeting notes or needs?
*
E.x. Bi-Lingual agents
What is the type of group meeting?
*
In-Person (Single)
In-Person (Multiple)
Hybrid (Virtual & In-Person)
Virtual
Is the Enrollment date and time set?
*
Yes
No (Must Provide 3 Business Day Notice)
Date & Time of Enrollment
*
Additional Enrollment notes or needs?
*
E.x. Bi-Lingual enrollers
What is the type of enrollment?
*
In-Person
Hybrid (Virtual & In-Person)
Virtual (Call Center)
Was the Program Request Form sent to Home Office no less than 48 hours before enrollment?
*
Yes
Not Applicable
If "yes" to Program Request please list what was requested.
*
Value Add approval email from Home Office sent to
[email protected]
?
*
Yes
Not Applicable
Benefits Selections
(Options marked * Are THe Default)
Has a Quick Quote already been provided to
[email protected]
in lieu of product selections on this form?
*
Yes
No
Disability: ISTD
Plan Offered?
*
No - ISTD
Yes - ISTD
On/Off Job Selection
*
Not Offered
Off Job Only*
On & Off Job
Both
Benefits Periods
*
ISTD - 3*
ISTD - 6*
ISTD - 12
ISTD - 24
Employer Riders
*
First Day Hospital
Psychology / Psychiatrics
Not Offered
Employee Riders
*
G.I. (Employed >6 Months)*
Health Screening
Not Offered*
Accident: IAC 4000
Plan Offered?
*
No - IAC 4000
Yes - IAC 4000
On/Off Job Selection
*
Not Offered
Off Job Only
On & Off Job*
Both
Plan Type
*
IAC 4000 Basic
IAC 4000 Preferred*
IAC 4000 Premier*
With Wellbeing?
*
Yes*
No
If "yes", what type of Wellbeing?
*
Not Applicable
Basic
Standard*
If "yes", what value of Wellbeing?
*
Not Applicable
$50*
$100
Disability Riders?
*
EE
SP
Neither
Active Lifestyle Rider?
*
Yes
No
Gunshot Rider
*
No
Yes, $1,000
Yes, $5,000
Yes, $1,000 & $5,000
Critical Illness Rider?
*
No
Yes, $2,500
Yes, $5,000
Yes, $2,500 & $5,000
Sickness Hospital Confinement Rider?
*
No
Yes, $200
Yes, $400
Yes, All
Yes, None
Cancer Assist
Plan Offered?
*
No - Cancer Assist
Yes - Cancer Assist
Riders
*
Specific Disease*
Initial Diagnosis*
Progressive Payment Rider*
Not Offered
Plan Level
*
Cancer - 1
Cancer - 2
Cancer - 3*
Cancer - 4
Select all that apply.
Health Screening Rider
*
No
Yes, $100*
Yes, $75
Yes, $50
Yes, $25
Critical Illness 1.0
Plan Offered?
*
No, Critical Illness 1.0
Yes, Critical Illness 1.0
Plan Riders
*
Health Screening*
Subsequent Diagnosis*
HSA
Cancer (Cannot be Offered with Cancer Assist)
Not Offered
Dental: IDN 8100
Plan Offered?
*
No, IDN 8100
Yes, IDN 8100
Plan Level (Select Up to 2)
*
Preventive Only Plan (MAC) $750 | $50 per person per policy year | 100%/50%
Standard Plan (MAC) $1,000 | $50 per person per policy year | 100%/80%/50%
Enhanced Plan (MAC) $3,000 | $50 per person per policy year | 100%/80%/50%
Premier Plan (MAC) $5,000 | $50 per person per policy year | 100%/90%/60%
Freedom Plan (UCR) $1,000 | $50 per person per policy year | 100%/80%/50%
Freedom Premier Plan (UCR) $2,000 | $50 per person per policy year | 100%/80%/50%
Waive Waiting Period?
*
No
Yes (Rates Will Increase)
Retiree Option
*
None
Yes, Retiree Plan (MAC) $1,500 | $50 per person per policy year | 100%/80%/50%
If yes, policy will require underwriting review.
Employer Riders
*
Ortho
Not Offered
Employee Riders
*
Vision*
Not Offered
Hospital Confinement: IMB 7000
Plan Offered?
*
No, IMB 7000
Yes, IMB 7000
Health Screening Rider?
*
No
Yes, $50*
Yes, $100
Plan Type
*
IMB 7000 Type 1
IMB 7000 Type 2*
IMB 7000 Type 3
Not Offered
IMB7000 - Plan Level (Select Up to 2)
*
Level 1
Level 2
Level 3*
Level 4
Level 5*
Level 6
Not Offered
IMB7000 - Plan Option
*
Option 1*
Option 2
Option 3
Not Applicable (Plan Type 1)
Not Offered
Employer Riders
*
Medical Treatment Package
Not Offered
Employee Riders
*
Daily Hospital Confinement*
Enhanced ICU*
Not Offered
Life Insurance
Select One
*
No - Life Insurance
Yes - Life Insurance
Plans Offered
*
Term*
Whole*
Not Applicable
Additional Notes for Coordinator
*
Submit
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Agent Services
Ameriflex ePOP
New & Existing Case Checklist
Client Resources
Enrollment
HR Answers Now
About
Experiences
Contact
