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.Format: (000) 000-0000.
Type of Business*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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
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
Company Logo

Cancelof
Agency/Broker Information
Broker Name*

First NameLast Name
Broker NPN*
Broker Email*
example@example.com
Broker Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Who is your GoWell Sales Rep?*
If other, who have you been working with from the GoWell team?
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.Format: (000) 000-0000.
Address of General Agency*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 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 add Benefits in a Box*
Enter the Vision Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the Pet Insurance Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the Critical Illness Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the Accident Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the Hospital Indemnity Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the Short-term Disability Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the Long-term Disability Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the Basic Life Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the Voluntary Life Insurance Carrier. If none, put N/A or add Benefits in a Box*
Enter the HRA Carrier. If none, put N/A or add Benefits in a Box*
Enter the HSA Carrier. If none, put N/A or add Benefits in a Box*
Enter the FSA Carrier. If none, put N/A or add Benefits in a Box*
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? *
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 $450Wrap Document $250COBRA - Administered by Anuvi ($1 PEPM)Ransomware Identity Theft Protection ($9.95 PEPM)No additional services 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
Employer Bank Name*
Employer Bank Account Type*
Employer Routing Number*
Employer 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