New Case Profile Form Please enable JavaScript in your browser to complete this form. - Step 1 of 5To get started right away, fill out our online New Case Profile form below.Broker/Rep Contact InformationName *FirstLastEmail *Phone *Affiliation *Which best describes your current role? *Agent or BrokerCarrier or Union RepEmployeeEmployer or HR assistant/executivePlatform PartnerOtherOther RoleHow did you hear about us?Broker ReferralHR Executive ReferralColleague ReferralLinked InFacebookTwitterOtherPlease describe how you heard about usNextCase InformationGroup Legal Name *Number of Eligible Lives *Minimum of five participants.Anticipated Effective Month *Select a monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberAnticipated Effective Year *Select a year20232024202520262027Anticipated Enrollment Start Date *PreviousNextGroup Type *Choose a Group TypeEmployerUnionAssociationOtherOther Group TypeGroup Situs State/Territory *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingLocation StatesAll States and DistrictsAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPreviousNextWhich 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 *Choose a Billing FrequencyMonthly (12)Semi-Monthly (24)Bi-Weekly (26)Weekly (52)Premium amounts must be provided to PIOPAC with this mode.Premium Collection Methods NeededEmployer 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 *FirstLastOrganization Billing Contact Email *Organization Billing Contact Phone *Are there employer/organization contributions? *YesNoDefine the employer/organization contributions *Are contributions defined by class? *YesNoDefine the classes used *Who is paying the PIOPAC fee? *OrganizationEmployeeBothIf both, please define *Are there any pay cycles where benefits are not taken from? *YesNoPlease define *Employer/Organization Account InformationName of bank *Routing Number *Address of bank *Account Number *Name on Business Checking Account *EFT Payment MethodChecking (ACH)Cards (Debit & Credit Cards)PreviousNextHow will you provide demographic and payment information? *PlatformAgent Portal (agent.piopac.com)Paper Authorization FormsCensus UploadIf using Census Upload, data must be sent to inquiry@piopacco.com using the PIOPAC census data format.Platform *Benefit HarborEnroll ConfidentlyGoWell BenefitsInnovative Enrollment Solutions (IES)SelerixOtherOther 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?YesNoWhich carrier(s) do you intend to use?5 Star LifeAAICACIAETNAAPEXARAGAflac Group (CAIC)Aflac IndividualAgent Benefits ProgramAllstateAllstate ID ProtectionAmalgamated LifeAmerican FidelityAmerican NationalAmerican Public LifeAmeritasAnthemArgus Dental (AFLAC)Assurity LifeAuraBEAMBoston MutualBridgewell HealthCancer GuardianCareingtonColonial LifeCombinedCoterie (ACI TPA)Delta DentalDominionEase/NBFSAFree Market Administrators (FMA)Globe LifeGuardianHMSAHawaii Dental ServiceHealthcare2UHealthiestYouHighlight HealthInfoArmorKaiserKemperLeader’s LifeLegalEaseLifeExecLifeworksLincoln Financial GroupLoomis CompanyMASAMEDOVA HealthcareMKHCManhattan LifeMass MutualMetLifeMetLife WebsuranceMutual of OmahaNBFSANational Dental (Lindsey Healthcare)National GeneralNational Vision Administrators (NVA)NationwideNew BenefitsNew Life EraOne AmericaOptions PlusPIOPACPRAMPet Benefit SolutionsPinnacle CarePrincipalRegional CareReliance StandardReliance Standard LifeResponders Health LLCS&S HealthSBMASEDERASun LifeTeladocThe HartfordThe StandardTransamerica (TEB)UHC GlobalUNUMUS LegalUnited HealthcareUnited WayVSPVaultVoyaWashington NationalWellFleetZurich (AFLAC)I have a carrier that is not listed (please specify below)5 Star Life ProductsAccidentCritical IllnessFamily Protection Group PlanHealthcare IndemnityHospitalTerm Life to 100AAIC ProductsAAIC MembershipACI ProductsACCCIGLIHIMECMEC w/Globe LifeSTDAETNA ProductsAccidentCritical IllnessDentalDental DHMODental PPOHospital IndemnityMedical HighMedical LowMedical MedVisionAPEX ProductsCare VisionCritical IllnessDentalMECARAG ProductsACCCILegal PlanAflac Group (CAIC) ProductsACAFBECICTRDNHISTTLVSWLAflac Individual ProductsACCCANCERCCRCRITCAREDENTALHOSPICAREJuvenile Whole LifeLIFELump Sum CIMedical AdvocatePSISPEVNTSTDSTDITerm LifeVISIONWhole LifeAgent Benefits Program ProductsBasic Health CareIdentity Theft Protection Featuring Legal ServiceAllstate ProductsAIP SelectAccidentCancerChild Term Rider (WL)CommonCritical IllnessDI PreferredDI StandardHospitalHospital Indemnity (SHOP)Long Term CareSTDTerm LifeTerm Life ChildTerm Life SpouseWhole LifeWhole Life CWhole Life C2Whole Life C3Whole Life C4Whole Life C5Whole Life C6Whole Life SAllstate ID Protection ProductsID ProtectionAmalgamated Life ProductsTerm LifeAmerican Fidelity ProductsAccidentCancerDisabilityHospitalLTDSTDTerm LifeVisionWhole LifeAmerican National ProductsACCCIDisabilityGenesis FlexcareLifeLimited MedicalSTDShort Term DisabilityTLAmerican Public Life ProductsMedLInk 6 - GAPAmeritas ProductsDentalVisionAnthem ProductsBlue View VisionEssential Choice DentalHealth Access 100Health Access 250Health Access 50Health Access CoreHospital HighHospital LowVoluntary Term LifeArgus Dental (AFLAC) ProductsDENTALVISIONAssurity ProductsACCCIHISTDAura ProductsID TheftBeam ProductsDentalVisionBoston Mutual ProductsAccidentCritical IllnessELOP Life ProductInfinite LifeLegacy LifeTerm to 100Whole Life Bridgewell Health ProductsLimited MedicalCancer Guardian ProductsCancerCareington ProductsDVRx PerksDentalRxVisionColonial Life ProductsCancerCritical IllnessDentalDisabilityHospitalMedical BridgeTerm LifeVisionWhole LifeCombined ProductsACCCIHDBHILBTLBT W/LTCSTDULCoterie (ACI TPA) ProductsMedical Plan 1Medical Plan 2Delta Dental ProductsDentalDominion ProductsDentalVisionEase/NBFSA ProductsGlobal Data LPFree Market Administrators (FMA) ProductsGlobal Data LPGlobe Life ProductsACCCIGLIHISTDGuardian ProductsAccidentCancerCritical IllnessDentalGSHAP Advantage PlanGSHAP Premier PlanGSHAP Value PlanHospitalLTDLifeSTDVisionReliance Standard LifeDentalVisionWashington NationalAccidentCancerCritical IllnessUniversal LifePlease 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 formPreviousSubmit Having trouble with the online form? 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