New Case Profile Form

- Step 1 of 5

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 *

Number of Eligible Lives *

Minimum of five participants.

Layout

Anticipated Effective Month *

Anticipated Effective Year *

Anticipated Enrollment Start Date *

Group Type *

Other Group Type

Group Situs State/Territory *

Location States

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)
Direct Deposit Pay (DDP)
Electronic Funds Transfer (EFT)

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

Layout

Name of bank *

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
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
Mass Mutual
MetLife
MetLife Websurance
Mutual of Omaha
NBFSA
National Dental (Lindsey Healthcare)
National General
National Vision Administrators (NVA)
Nationwide
New Benefits
New Life Era
One America
Options Plus
PIOPAC
PRAM
Pet Benefit Solutions
Pinnacle Care
Principal
Regional Care
Reliance Standard
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
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

AAIC Products

AAIC Membership

ACI Products

ACC
CI
GLI
HI
MEC
MEC w/Globe Life
STD

AETNA Products

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

APEX Products

Care Vision
Critical Illness
Dental
MEC

ARAG Products

ACC
CI
Legal Plan

Aflac Group (CAIC) Products

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

Agent Benefits Program Products

Basic Health Care
Identity Theft Protection Featuring Legal Service

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 ID Protection Products

ID Protection

Amalgamated Life Products

Term Life

American Fidelity Products

Accident
Cancer
Disability
Hospital
LTD
STD
Term Life
Vision
Whole Life

American National Products

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

American Public Life Products

MedLInk 6 - GAP

Ameritas Products

Dental
Vision

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

Argus Dental (AFLAC) Products

DENTAL
VISION

Assurity Products

Aura Products

ID Theft

Beam Products

Dental
Vision

Boston Mutual Products

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

Bridgewell Health Products

Limited Medical

Cancer Guardian Products

Cancer

Careington Products

DVRx Perks
Dental
Rx
Vision

Colonial Life Products

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

Combined Products

ACC
CI
GDI
HDB
HI
LBT
LBT W/LTC
STD
UL

Coterie (ACI TPA) Products

Medical Plan 1
Medical Plan 2

Delta Dental Products

Dental

Dominion Products

Dental
Vision

Ease/NBFSA Products

Global Data LP

Free Market Administrators (FMA) Products

Global Data LP

Globe Life Products

Guardian Products

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

Which carrier(s) not listed above do you wish to use?

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

Please list products for each carrier and share other important information related to this case we should know.

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New Case Profile Form

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