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New Case Profile Form

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

- Step 1 of 5

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

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

Which services do you anticipate needing? *

Flexible Spending Accounts (FSA)
Health Reimbursement Accounts (HRA)
COBRA Administration
Lifestyle Spending Account (LSA)
Premium Facilitation
I'm Not Sure

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)

EFT Payment Method

Checking (ACH)
Cards (Debit & Credit Cards)

Do you intend to utilize a platform?

Yes
No

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.

How will you provide payment information? *

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

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

Yes
No

Which carrier(s) do you intend to use?

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

Having trouble with the online form? Fill out and return our PDF New Case Profile form.

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When you reach out to us, you’ll meet a real human being. Our talented people have a combined 200 years of experience in benefits insurance and consulting. Let us put our expertise to work for YOU.

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Address

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