New Case Profile Form

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To get started right away, fill out our online New Case Profile form below.

Broker/Rep Contact Information

Name *

First

Last

Email *

Phone *

Affiliation *

Which best describes your current role? *

Agent or Broker
Carrier or Union Rep
Employee
Employer or HR assistant/executive
Platform Partner
Other

Other Role

How did you hear about us?

Broker Referral
HR Executive Referral
Colleague Referral
Linked In
Facebook
Twitter
Other

Please describe how you heard about us

Case Information

Group Legal Name *

EIN *

Number of Eligible Lives *

Minimum of five participants.

Anticipated Effective Month *

Anticipated Effective Year *

Anticipated Enrollment Start Date *

Group Type *

Other Group Type

Group Situs State/Territory *

Location States

All States and Districts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

Which services do you anticipate needing? *

Flexible Spending Accounts (FSA) - Tax-advantaged accounts allowing your employees to pay for qualified out-of-pocket expenses with pre-tax dollars.
Health Reimbursement Accounts (HRA) - Employer funded tax-advantaged accounts that help employees with out-of-pocket expenses and insurance premium reimbursements.
COBRA Administration - Gain piece of mind by minimizing your liability when it comes to time spent administering COBRA.
Lifestyle Spending Accounts (LSA) - Employer funded accounts that provide employees the freedom to select the type of eligible expenses covered.
Premium Facilitation - Attract and retain members and employees by offering them benefits without the typically associated burdens and costs.

First Draft/Payroll Date *

Second Draft/Payroll Date *

Draft/Payroll Deduction Frequency *

Premium amounts must be provided to PIOPAC with this mode.

Premium Collection Methods Needed

Employer Deduction Draft (EDD) - PIOPAC receives the list of deductions from System of Record or organization and drafts the deduction total from the organization account in one transaction.
Direct Deposit Pay (DDP) - A unique routing and account number is assigned for each participant, the unique routing and account number is provided to an participant’s payroll system, premiums are then redirected from the payroll system on each pay cycle.
Electronic Funds Transfer (EFT) - PIOPAC drafts participant’s checking account or processes card payment. This method circumvents payroll and does not require any involvement of the organization.

A billing call with the organization to coordinate timelines and process will need to take place.

Organization Billing Contact Name *

First

Last

Organization Billing Contact Email *

Organization Billing Contact Phone *

Are there employer/organization contributions? *

Define the employer/organization contributions *

Are contributions defined by class? *

Define the classes used *

Who is paying the PIOPAC fee? *

Organization
Employee
Both

If both, please define *

Are there any pay cycles where benefits are not taken from? *

Please define *

Employer/Organization Account Information

Name of bank

Routing Number

Enter 9-digit routing number

Address of bank

Account Number

Name on Business Checking Account

EFT Payment Method

Checking (ACH)
Cards (Debit & Credit Cards)

How will you provide demographic and payment information? *

Platform
Agent Portal (agent.piopac.com)
Paper Authorization Forms
Census Upload

If using Census Upload, data must be sent to inquiry@piopacco.com using the PIOPAC census data format.

Platform *

Other Platform *

Note: Using a platform other than a preferred partner listed above will prohibit the single sign-on experience and require payment methods be entered into the system independent of the platform.

Do you know the carrier(s) you intend to use?

Which carrier(s) do you intend to use?

5 Star Life
AAIC
ACI
AETNA
APEX
ARAG
Aflac Group (CAIC)
Aflac Individual
Agent Benefits Program
Allstate
Allstate ID Protection
Amalgamated Life
American Fidelity
American National
American Public Life
Ameritas
Anthem
Argus Dental (AFLAC)
Assurity Life
Aura
BEAM
Boston Mutual
Bridgewell Health
Cancer Guardian
Careington
Colonial Life
Combined
Coterie (ACI TPA)
Delta Dental
Dominion
Ease/NBFSA
Free Market Administrators (FMA)
Globe Life
Guardian
Hale Makua Health Services
HBA - TPA
HMSA
Hawaii Dental Service
Healthcare2U
HealthiestYou
Highlight Health
InfoArmor
Kaiser
Kemper
Leader’s Life
LegalEase
LifeExec
Lifeworks
Lincoln Financial Group
Loomis Company
MASA
MEDOVA Healthcare
MKHC
Manhattan Life
Marpai
Mass Mutual
Medova Admin Fee
MetLife
MetLife Websurance
Mutual of Omaha
NAIT Membership Fees
NBFSA
National Dental (Lindsey Healthcare)
National General
National Plan Administrators
National Vision Administrators (NVA)
Nationwide
New Benefits
New Life Era
One America
Options Plus
PIOPAC
PRAM
Pet Benefit Solutions
Pinnacle Care
Presidential Life
Principal
Profit Forward LLC
Regional Care
Reliance Matrix
Reliance Standard
Reliance Standard Life
Responders Health LLC
S&S Health
SBMA
SEDERA
Sun Life
Teladoc
The Hartford
The Standard
Transamerica (TEB)
UHC Global
UNUM
US Legal
United Healthcare
United Way
VSP
Vault
Voya
Washington National
WellFleet
Zurich (AFLAC)
I have a carrier that is not listed (please specify below)

5 Star Life Products

Accident
Critical Illness
Family Protection Group Plan
Healthcare Indemnity
Hospital
Term Life to 100

5 Star Life Group Number

AAIC Products

AAIC Membership

AAIC Group Number

ACI Products

ACC
CI
GLI
HI
MEC
MEC w/Globe Life
STD

ACI Group Number

AETNA Products

Accident
Critical Illness
Dental
Dental DHMO
Dental PPO
Hospital Indemnity
Medical High
Medical Low
Medical Med
Vision

AETNA Group Number

APEX Products

Care Vision
Critical Illness
Dental
MEC

APEX Group Number

ARAG Products

ACC
CI
Legal Plan

ARAG Group Number

Aflac Group (CAIC) Products

Aflac Group (CAIC) Group Number

Aflac Individual Products

ACC
CANCER
CCR
CRITCARE
DENTAL
HOSP
ICARE
Juvenile Whole Life
LIFE
Lump Sum CI
Medical Advocate
PSI
SPEVNT
STD
STDI
Term Life
VISION
Whole Life

Aflac Individual Group Number

Agent Benefits Program Products

Basic Health Care
Identity Theft Protection Featuring Legal Service

Agent Benefits Group Number

Allstate Products

AIP Select
Accident
Cancer
Child Term Rider (WL)
Common
Critical Illness
DI Preferred
DI Standard
Hospital
Hospital Indemnity (SHOP)
Long Term Care
STD
Term Life
Term Life Child
Term Life Spouse
Whole Life
Whole Life C
Whole Life C2
Whole Life C3
Whole Life C4
Whole Life C5
Whole Life C6
Whole Life S

Allstate Carrier Group Number

Allstate ID Protection Products

ID Protection

Allstate ID Protection Group Number

Amalgamated Life Products

Term Life

Amalgamated Life Group Number

American Fidelity Products

Accident
Cancer
Disability
Hospital
LTD
STD
Term Life
Vision
Whole Life

American Fidelity Group Number

American National Products

ACC
CI
Disability
Genesis Flexcare
Life
Limited Medical
STD
Short Term Disability
TL

American National Group Number

American Public Life Products

MedLInk 6 - GAP

American Public Life Group Number

Ameritas Products

Dental
Vision

Ameritas Group Number

Anthem Products

Blue View Vision
Essential Choice Dental
Health Access 100
Health Access 250
Health Access 50
Health Access Core
Hospital High
Hospital Low
Voluntary Term Life

Anthem Group Number

Argus Dental (AFLAC) Products

DENTAL
VISION

Argus Dental (AFLAC) Group Number

Assurity Products

Assurity Group Number

Aura Products

ID Theft

Aura Group Number

Beam Products

Dental
Vision

Beam Group Number

Boston Mutual Products

Accident
Critical Illness
ELOP Life Product
Infinite Life
Legacy Life
Term to 100
Whole Life

Boston Mutual Group Number

Bridgewell Health Products

Limited Medical

Bridgewell Health Group Number

Cancer Guardian Products

Cancer

Cancer Guardian Group Number

Careington Products

DVRx Perks
Dental
Rx
Vision

Careington Group Number

Colonial Life Products

Accident
Cancer
Critical Illness
Dental
Disability
Hospital
Medical Bridge
Term Life
Vision
Whole Life

Colonial Life Group Number

Combined Products

ACC
CI
HDB
HI
LBT
LBT W/LTC
STD
UL

Combined Group Number

Coterie (ACI TPA) Products

Medical Plan 1
Medical Plan 2

Coterie (ACI TPA) Group Number

Delta Dental Products

Dental

Delta Dental Group Number

Dominion Products

Dental
Vision

Dominion Group Number

Ease/NBFSA Products

Global Data LP

Ease/NBFSA Group Number

Free Market Administrators (FMA) Products

Global Data LP

Free Market Administrators (FMA) Group Number

Globe Life Products

Globe Life Group Number

Guardian Products

Accident
Cancer
Critical Illness
Dental
GSHAP Advantage Plan
GSHAP Premier Plan
GSHAP Value Plan
Hospital
LTD
Life
STD
Vision

Guardian Group Number

Hale Makua Health Services Products

Medical

Hale Makua Health Services Group Number

HBA - TPA Products

HBA Bronze
HBA Essential Value

HBA - TPA Group Number

HMSA Products

HMO Bundle w/HDS
HMO Plan
PPO Bundle w/ HDS
PPO Plan

HMSA Group Number

Hawaii Dental Service Products

Dental

Hawaii Dental Service Group Number

Healthcare2U Products

Healthcare Benefit Package
Medical Membership

Healthcare2U Group Number

HealthiestYou Products

Teledoc

HealthiestYou Group Number

Highlight Health Products

Basic Medical
Premium Medical
Standard Medical

Highlight Health Group Number

InfoArmor Products

ID Theft
Privacy Armor Plus

InfoArmor Group Number

Kaiser Products

Med Bundle w/HDS
Medical

Kaiser Group Number

Kemper Products

LIFE
LTD MED

Kemper Group Number

Leader's Life Products

Accident (GACC)
STD (VSDI)
Term to 100 (T100)
Term to 100 w/CI

Leader's Life Group Number

LegalEase Products

Legal Insurance - Basic
Legal Insurance - Platinum

LegalEase Group Number

LifeExec Products

LifeExec

LifeExec Group Number

Lifeworks Products

MAP & Wellness Program

Lifeworks Group Number

Lincoln Financial Group Products

Lincoln Financial Group Group Number

Loomis Company Products

Amalgamated Life
Ameritas Dental
Ameritas Vision
Globe Life MEC
Globe Life STD
IHP Basic
IHP Plus
IHP Premier
IHP Ultimate

Loomis Company Group Number

MASA Products

Emergent Plus

MASA Group Number

MEDOVA Healthcare Products

Dental
Invoice Fees
Limited Medical
Medical
Medical Limited
Vision

MEDOVA Healthcare Group Number

MKHC Products

DENTAL
MEDICAL
MKHC CoOP w/RX
VISION

MKHC Group Number

Manhattan Life Products

Accident
Critical Illness
Dental/Vision Indemnity
Disability (On the job)
Disability - Off the job
Short Term Disability
Term Life
Term Life - 10 year
Term Life - 20 year

Manhattan Life Group Number

Marpai Products

Marpai Group Number

Mass Mutual Products

Whole Life

Mass Mutual Group Number

Medova Admin Fee Products

Monthly Admin Fee

Medova Admin Fee Group Number

MetLife Products

ACC
AD&D
Benefits Bundle
CI
DENTAL
Dental/Vision
HOSP
LEGAL PLAN
LIFE (EE ONLY)
LIFE (SPOUSE)
LTD
STD
VISION

MetLife Group Number

MetLife Websurance Products

Basic Dental
Basic Vision
Premium Dental
Premium Vision

MetLife Websurance Group Number

Mutual of Omaha Products

Vision

Mutual of Omaha Group Number

NAIT Membership Fees Products

Membership Fee

NAIT Membership Fees Group Number

NBFSA Products

Evolved Benefits Comp
Global Data LP
Joel Comp
TruScript Rx
TruScript Rx Package

NBFSA Group Number

National Dental (Lindsey Healthcare) Products

Care
Dental
SBA

National Dental (Lindsey Healthcare) Group Number

National General Products

Medical

National General Group Number

National Plan Administrators Products

Membership Fees

National Plan Administrators Group Number

National Vision Administrators (NVA) Products

Vision

National Vision Administrators (NVA) Group Number

Nationwide Products

Dental
Pet Insurance

Nationwide Group Number

New Benefits Products

Basic Health Care
Identity Theft Protection Featuring Legal Service
MeMD Teledoc

New Benefits Group Number

New Life Era Products

Accident
Hospital

New Life Era Group Number

One America Products

Group Term Life
Group Term Life - Children
Group Term Life - Spouse
STD

One America Group Number

Options Plus Products

MEC Plan

Options Plus Group Number

PRAM Products

RX - EC (Member & Child)
RX - EO (Member Only)
RX - ES (Member & Spouse)
RX - FM (Family)

PRAM Group Number

Pet Benefit Solutions Products

Pet Benefits
Pet Insurance

Pet Benefit Solutions Group Number

Pinnacle Care Products

Medical Review

Pinnacle Care Group Number

Presidential Life Products

Accident
Cancer
Critical Illness
Hospital Indemnity
Life
Short Term Disability

Principal Products

Dental
Vision

Principal Group Number

Profit Forward LLC Products

AFLAC
Allstate Benefits
AmFirst
Guardian
Trustmark

Profit Forward LLC Group Number

Regional Care Products

GLIADV2
LRGDENTAL
MECBASIC
MECPLUSADV
NOMEC
VSPPLAN

Regional Care Group Number

Reliance Matrix Products

GL Supplemental Life
Long Term Care
Short Term Disability
Term Life
VAI Accident
VAR AD&D
VCI Critical Illness
VHI Hospital
VPL Long Term Disability
VPS Short Term Disability

Reliance Matrix Group Number

Reliance Standard Life Products

Dental
Vision

Reliance Standard Life Group Number

S&S Health Products

3500 HSA
3500 PPO
5000 HSA
5000 PPO
IHP Basic
IHP MEC 1
IHP MEC 2
IHP Plus
IHP Premier
IHP Ultimate
IHP Ultimate Plan $5K HSA
PrimarySelect
Select 1500 PPO
Select 2500 PPO
Select 3500 PPO
Select 6500 HDHP
Self-funded Medical
WellSelect

S&S Health Group Number

SBMA Health Products

Anthem Vision
Basic MEC + TEB Opt 1
Beazley Deluxe
Beazley Standard Package
Delta 1000 Plan
Delta Comprehensive Dental
Delta Dental
Delta High Opt 1500
Delta Preventive Dental
Delta Preventive Plan
EliteCare MEC
MEC
MEC Basic
MEC Plus
MET Advantage Pack
MET Term Life
MET Vision
MeMD Teledoc
OptimaCare
Options Plus VSP
PrimeCare MEC
Protection Pack
Protection Pack Plus
Ult MEC + TEB Opt 2
Ultimate MEC
Ultra MEC
VSP 130 Plan
VSP Vision

SBMA Health Group Number

SEDERA Products

MEDICAL

SEDERA Group Number

Sun Life Products

AD&D
Accident
Cancer
Critical Illness
Dental
Hospital
LTD
Life
STD
Vision

Sun Life Group Number

Teladoc Products

Telehealth

Teladoc Group Number

The Hartford Products

The Hartford Group Number

The Standard Products

Accident
Critical Illness
Hospital
STD

The Standard Group Number

Transamerica (TEB) Products

Accident
CTLI
Cancer
Critical Illness
Disability
Hospital Indemnity
Limited Medical
Permanent Life
Term
Term - Spouse
Universal Life
Whole Life

Transamerica (TEB) Group Number

UHC Global Products

Dental
Medical
Vision

UHC Global Group Number

UNUM Products

AD&D
Accident
Critical Illness
Hospital
LTD
Life
STD

UNUM Group Number

US Legal Products

CDL Defender
Family Defender
Family Pro Driver

US Legal Group Number

United Healthcare Products

Dental
Medical
Vision

United Healthcare Group Number

United Way Products

Donation

United Way Group Number

VSP Products

Care
Care Vision
Vision

VSP Group Number

Vault Products

Healthcare Benefit Package
Medical

Vault Group Number

Voya Products

Accident
Critical Illness

Voya Group Number

Washington National Products

Accident
Cancer
Critical Illness
Hospital
Universal Life

Washington National Group Number

WellFleet Products

Accident
Critical Illness
STD
Short Term Disability

WellFleet Group Number

Zurich (AFLAC) Products

Life

Zurich (AFLAC) Group Number

Please list any carrier(s) and/or product(s) not listed above do you wish to use?

We will reach out to you to discuss usage of the carrier(s) and product(s) listed above.

Please add any pertinent information not already provided elsewhere in this form

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