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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

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

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.
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)

How will you provide the initial census data to PIOPAC? *

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.

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? *

Yes
No

Define the employer/organization contributions *

Are contributions defined by class? *

Yes
No

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? *

Yes
No

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)

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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888-561-3232

Address

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Honolulu, HI 96813