Daniels District

Daniels District New case form

Agent Information

* Indicates required field

Primary Agent Name *

First

Last

Primary Agent Email *

Primary Agent Phone Number *

Primary Agent Code *

Secondary Agent Name *

First

Last

Secondary Agent Email *

Secondary Agent Phone Number *

Secondary Agent Code *

Commission Split If Applicable *

Broker Name (If Appl.) *

Broker Commission Schedule (If Appl.) *

Commission Code *

New Case Information

Are we enrolling core products? *

Account Name *

Case Count *

BCN *

CAN *

Risk Class *

Coverage Effective Date *

Policy Effective Date *

Benefit Bank? *

Employer Paid? *

Notes on Benefit Bank and/or Employer Paid *

Pre-Enrollment: Opener Responsbilities

Fast Forms signed, Sent to Home Office and newcases@corcoranhoyt.com? *

Yes

Re-Work? *

Yes No

Was CASSHM completed? *

Yes No

ePOP, if Pre-Tax, sent to NewCases@corcoranhoyt.com? *

Yes Not Pre-Tax

Is Group Meeting date and time set? *

Yes No

Date & Time of Group Meeting *

Additional Group Meeting notes or needs? *

What is the type of group meeting? *

Is the Enrollment date and time set? *

Yes No (Must Provide 3 Business Day Notice)

Date & Time of Enrollment *

Additional Enrollment notes or needs? *

What is the type of enrollment? *

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. *

Are CORE benefits being offered? *

Benefits Selections (Options marked * Are THe Default)

Has a Quick Quote already been provided to newcases@corcoranhoyt.com in lieu of product selections on this form? *

Yes No

Disability: ISTD

Plan Offered? *

On/Off Job Selection *

Accident: IAC 4000

Plan Offered? *

On/Off Job Selection *

Plan Type *

IAC 4000 Basic IAC 4000 Preferred* IAC 4000 Premier*

With Wellbeing? *

Yes No

If "yes", what type of Wellbeing? *

If "yes", what value of Wellbeing? *

Disability Riders? *

EE SP Neither

Active Lifestyle Rider? *

Yes No

Gunshot Rider *

Critical Illness Rider? *

Sickness Hospital Confinement Rider? *

Cancer Assist

Plan Offered? *

Plan Level *

Cancer - 1 Cancer - 2 Cancer - 3 Cancer - 4

Riders *

Specific Disease* Initial Diagnosis* Progressive Payment Rider* Not Offered

Health Screening Rider *

Critical Illness 1.0

Plan Offered? *

Dental: IDN 8000

Hospital Confinement: IMB 7000

Plan Offered? *

Health Screening Rider? *

Life Insurance

Select One *

Plans Offered *

Term* Whole* Not Applicable

Additional Notes for Coordinator *

Submit