New/Renewal Group Case Install Form

Case Installation

Company Information
Case Status*

NewRenewal
Company Name*
Company EIN Number*
Company Phone Number*
Please enter a valid phone number.
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Business*
Company Contact Name*

First NameLast Name
Company Contact Position (Business Owner, HR, Administrator, etc.)*
Company Contact Email*
example@example.com
Number of Eligible Employees*
Employee Waiting Period*
Payroll Frequency*
Employee Pay Type *
Please note Employee Direct Pay requires at least 1st of the month following 30 day wait time
Agency/Broker Information
Are you working with a General Agent?*
General Agent Name*

First NameLast Name
General Agent Email*
example@example.com
General Agent Phone Number*
Please enter a valid phone number.
Address of General Agency*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Broker Name*

First NameLast Name
Broker NPN*
Broker Email*
example@example.com
Broker Phone Number*
Please enter a valid phone number.
Who is your GoWell Sales Rep?*
If other, who have you been working with from the GoWell team?
Benefit Offerings
Are there different classes that have different benefits offerings or employer contribution amounts? *
If yes, list the different classes below.*
If the company has different classes that recieve different benefit offerings or employer contributions, please note: each class of employees will have their own company code to register with to enroll. The HR/admin will receive one login to manage all.
What plans are you planning on offering on GoWell?*

MedicalMEC/MVPDentalVisionShort-Term DisabilityLong-Term DisabilityAccidentCritical IllnessHospital IndemnityBasic LifeVoluntary LifeFSAHSAHRAPet Insurance
Employer Contribution Strategy*

Employer Dollar amountEmployer PercentageACA ContributionN/A
Enter the Employer's Contribution for Medical. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for MEC/MVP. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Dental. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Vision. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Short-Term Disability. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Long-Term Disability. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Accident. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Critical Illness. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Hospital Indemnity. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Basic Life. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for Voluntary Life. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for FSA. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for HSA. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for HRA. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Employer's Contribution for HRA. If none, put N/A.*
Please specify if it's a flat dollar amount or percentage.
Enter the Medical Insurance Carrier. If none, put N/A.*
Enter the MEC/MVP Insurance Carrier. If none, put N/A.*
Enter the Dental Insurance Carrier. If none, put N/A Or please add Benefits in ab Box*
Enter the Vision Insurance Carrier. If none, put N/A Or please add Benefits in ab Box*
Enter the Pet Insurance Insurance Carrier. If none, put N/A Or please add Benefits in ab Box*
Enter the Critical Illness Insurance Carrier. If none, put N/A Or please add Benefits in ab Box*
Enter the Accident Insurance Carrier. If none, put N/A Or please add Benefits in ab Box*
Enter the Hospital Indemnity Insurance Carrier. If none, put N/A Or please add Benefits in ab Box*
Enter the Life Insurance Carrier. If none, put N/A Or please add Benefits in ab Box*
Plan Year Effective Date*

MonthDayYear
Date
Plan Year End Date*

MonthDayYear
Date
What date do you want the enrollment site opened?*

MonthDayYear
Date
What date do you want the enrollment site closed? (please note before the 15th of the month for the following 1st of the month start is ideal)*

MonthDayYear
Date
Communication
Email Communication Required (Free service - sent from GoWell)*

Yes (Upload a census below to include employee names and email addresses)No (Our company will manage sending out emails)
Text Communication Required (Additional service cost listed below)*

Yes (Upload a census below to include employee names and mobile numbers)No
Text Message Pricing - Per Round*

0-25 Employees - $4025-50 Employees - $7550-75 Employees - $11575-100 Employees - $150100-200 Employees - $300200-500 Employees - $750500-1000 Employees - $1,500No Text
How many rounds of text are desired? *
Company Logo

Cancelof
Plan Documents and Rates
Upload Plan Documents for all plans

Cancelof
Upload sold plan rates/proposals for all plans

Cancelof
Please note any additional information that would be helpful for GoWell to know!
Enter any additional information that could be helpful during the install.
Add-on Services
Optional Add-on Services*

Nondiscrimination Testing Doc $500POP Doc $2501095 Form $6 per form1095 Form (with postage - if mailing is needed) $7.95 per form1094 Form $500Form 5500 $350Wrap Document $250COBRA - Administered by Anuvi (Ask for rates)No add-ons needed
Are you interested in adding GoWell's Ancillary Products?*
Here is a list of our partners for Dental and Vision coverage. Please select any of the below that you are interested in getting a quote for. (Must upload a census in the dropbox below for a quote to be completed)

MetLife/VBADominion/VSPDelta Dental/VSPBeam/VSPCombined InsuranceNot Interested
Employee Census*

Cancelof
Employer Billing
Bank Name*
Bank Account Type*
Routing Number*
Account Number*
Date for 1st Payment Draft*

MonthDayYear
Date
Agreement
Date*

MonthDayYear
Date
Name*

First NameLast Name
I accept these plans and would like to offer these plans to my employees.*

Clear
Signature
Should be Empty:

Case Installation

Agency/Broker Information

Benefit Offerings

Communication

Plan Documents and Rates

Add-on Services

Employer Billing

Agreement