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 *

Are you submitting this form on someone else's behalf? *

Submitter Name *

First

Last

Submitter 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 *

Please enter a 9-digit 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 (user.piopacfidelity.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 Argus
Aflac Group (CAIC)
Aflac Individual
Agent Benefits Program
Allstate
Allstate ID Protection
Amalgamated Life
American Fidelity
American National
American Public Life
Ameritas
Anthem
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
MKHC
Manhattan Life
Marpai
Mass Mutual
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 Argus (AFLAC) Products *

DENTAL
VISION

Aflac Argus Dental (AFLAC) Group Number *

Aflac Group (CAIC) Products *

* If you are setting up Argus Dental or Vision, please select "Argus Dental (AFLAC)" as a carrier above.

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

* If you are setting up Argus Dental or Vision, please select "Argus Dental (AFLAC)" as a carrier above.

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 *

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
TERM LIFE

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 *

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 *

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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New Case Profile Form

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