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 *Are you submitting this form on someone else's behalf? *YesNoSubmitter Name *FirstLastSubmitter Email *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 *EIN *Please enter a 9-digit EINNumber of Eligible Lives *Minimum of five participants.Anticipated Effective Month *Select a monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberAnticipated Effective Year *Select a year20262027Anticipated 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 bankRouting NumberEnter 9-digit routing numberAddress of bankAccount NumberName on Business Checking AccountEFT Payment MethodChecking (ACH)Cards (Debit & Credit Cards)PreviousNextHow will you provide demographic and payment information? *PlatformAgent Portal (user.piopacfidelity.com)Paper Authorization FormsCensus UploadIf using Census Upload, data must be sent to inquiry@piopacco.com using the PIOPAC census data format.Platform *Benefit HarborClickEnrollEnroll ConfidentlyInnovative 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 ArgusAflac Group (CAIC)Aflac IndividualAgent Benefits ProgramAllstateAllstate ID ProtectionAmalgamated LifeAmerican FidelityAmerican NationalAmerican Public LifeAmeritasAnthemAssurity LifeAuraBEAMBoston MutualBridgewell HealthCancer GuardianCareingtonColonial LifeCombinedCoterie (ACI TPA)Delta DentalDominionEase/NBFSAFree Market Administrators (FMA)Globe LifeGuardianHale Makua Health ServicesHBA - TPAHMSAHawaii Dental ServiceHealthcare2UHealthiestYouHighlight HealthInfoArmorKaiserKemperLeader’s LifeLegalEaseLifeExecLifeworksLincoln Financial GroupLoomis CompanyMASAMKHCManhattan LifeMarpaiMass MutualMetLifeMetLife WebsuranceMutual of OmahaNAIT Membership FeesNBFSANational Dental (Lindsey Healthcare)National GeneralNational Plan AdministratorsNational Vision Administrators (NVA)NationwideNew BenefitsNew Life EraOne AmericaOptions PlusPIOPACPRAMPet Benefit SolutionsPinnacle CarePresidential LifePrincipalProfit Forward LLCRegional CareReliance MatrixReliance 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 Products *AccidentCritical IllnessFamily Protection Group PlanHealthcare IndemnityHospitalTerm Life to 1005 Star Life Group Number *AAIC Products *AAIC MembershipAAIC Group Number *ACI Products *ACCCIGLIHIMECMEC w/Globe LifeSTDACI Group Number *AETNA Products *AccidentCritical IllnessDentalDental DHMODental PPOHospital IndemnityMedical HighMedical LowMedical MedVisionAETNA Group Number *APEX Products *Care VisionCritical IllnessDentalMECAPEX Group Number *ARAG Products *ACCCILegal PlanARAG Group Number *Aflac Argus (AFLAC) Products *DENTALVISIONAflac Argus Dental (AFLAC) Group Number *Aflac Group (CAIC) Products *ACAFBECICTRDN*HISTTLVS*WL* 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 *ACCCANCERCCRCRITCAREDENTAL*HOSPICAREJuvenile Whole LifeLIFELump Sum CIMedical AdvocatePSISPEVNTSTDSTDITerm LifeVISION*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 CareIdentity Theft Protection Featuring Legal ServiceAgent Benefits Group Number *Allstate Products *AIP 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 Carrier Group Number *Allstate ID Protection Products *ID ProtectionAllstate ID Protection Group Number *Amalgamated Life Products *Term LifeAmalgamated Life Group Number *American Fidelity Products *AccidentCancerDisabilityHospitalLTDSTDTerm LifeVisionWhole LifeAmerican Fidelity Group Number *American National Products *ACCCIDisabilityGenesis FlexcareLifeLimited MedicalSTDShort Term DisabilityTLAmerican National Group Number *American Public Life Products *MedLInk 6 - GAPAmerican Public Life Group Number *Ameritas Products *DentalVisionAmeritas Group Number *Anthem Products *Blue View VisionEssential Choice DentalHealth Access 100Health Access 250Health Access 50Health Access CoreHospital HighHospital LowVoluntary Term LifeAnthem Group Number *Assurity Products *ACCCIHISTDAssurity Group Number *Aura Products *ID TheftAura Group Number *Beam Products *DentalVisionBeam Group Number *Boston Mutual Products *AccidentCritical IllnessELOP Life ProductInfinite LifeLegacy LifeTerm to 100Whole LifeBoston Mutual Group Number * Bridgewell Health Products *Limited MedicalBridgewell Health Group Number *Cancer Guardian Products *CancerCancer Guardian Group Number *Careington Products *DVRx PerksDentalRxVisionCareington Group Number *Colonial Life Products *AccidentCancerCritical IllnessDentalDisabilityHospitalMedical BridgeTerm LifeVisionWhole LifeColonial Life Group Number *Combined Products *ACCCIHDBHILBTLBT W/LTCSTDULTERM LIFECombined Group Number *Coterie (ACI TPA) Products *Medical Plan 1Medical Plan 2Coterie (ACI TPA) Group Number *Delta Dental Products *DentalDelta Dental Group Number *Dominion Products *DentalVisionDominion Group Number *Ease/NBFSA Products *Global Data LPEase/NBFSA Group Number *Free Market Administrators (FMA) Products *Global Data LPFree Market Administrators (FMA) Group NumberGlobe Life Products *ACCCIGLIHISTDGlobe Life Group Number *Guardian Products *AccidentCancerCritical IllnessDentalGSHAP Advantage PlanGSHAP Premier PlanGSHAP Value PlanHospitalLTDLifeSTDVisionGuardian Group Number *Hale Makua Health Services Products *MedicalHale Makua Health Services Group Number *HBA - TPA Products *HBA BronzeHBA Essential ValueHBA - TPA Group Number *HMSA Products *HMO Bundle w/HDSHMO PlanPPO Bundle w/ HDSPPO PlanHMSA Group Number *Hawaii Dental Service Products *DentalHawaii Dental Service Group Number *Healthcare2U Products *Healthcare Benefit PackageMedical MembershipHealthcare2U Group Number *HealthiestYou Products *TeledocHealthiestYou Group Number *Highlight Health Products *Basic MedicalPremium MedicalStandard MedicalHighlight Health Group Number *InfoArmor Products *ID TheftPrivacy Armor PlusInfoArmor Group Number *Kaiser Products *Med Bundle w/HDSMedicalKaiser Group Number *Kemper Products *LIFELTD MEDKemper Group Number *Leader's Life Products *Accident (GACC)STD (VSDI)Term to 100 (T100)Term to 100 w/CILeader's Life Group Number *LegalEase Products *Legal Insurance - BasicLegal Insurance - PlatinumLegalEase Group Number *LifeExec Products *LifeExecLifeExec Group Number *Lifeworks Products *MAP & Wellness ProgramLifeworks Group Number *Lincoln Financial Group Products *LTDSTDLincoln Financial Group Group Number *Loomis Company Products *Amalgamated LifeAmeritas DentalAmeritas VisionGlobe Life MECGlobe Life STDIHP BasicIHP PlusIHP PremierIHP UltimateLoomis Company Group Number *MASA Products *Emergent PlusMASA Group Number *MKHC Products *DENTALMEDICALMKHC CoOP w/RXVISIONMKHC Group Number *Manhattan Life Products *AccidentCritical IllnessDental/Vision IndemnityDisability (On the job)Disability - Off the jobShort Term DisabilityTerm LifeTerm Life - 10 yearTerm Life - 20 yearManhattan Life Group Number *Marpai Products *MECMarpai Group Number *Mass Mutual Products *Whole LifeMass Mutual Group Number *MetLife Products *ACCAD&DBenefits BundleCIDENTALDental/VisionHOSPLEGAL PLANLIFE (EE ONLY)LIFE (SPOUSE)LTDSTDVISIONMetLife Group Number *MetLife Websurance Products *Basic DentalBasic VisionPremium DentalPremium VisionMetLife Websurance Group Number *Mutual of Omaha Products *VisionMutual of Omaha Group Number *NAIT Membership Fees Products *Membership FeeNAIT Membership Fees Group Number *NBFSA Products *Evolved Benefits CompGlobal Data LPJoel CompTruScript RxTruScript Rx PackageNBFSA Group Number *National Dental (Lindsey Healthcare) Products *CareDentalSBANational Dental (Lindsey Healthcare) Group Number *National General Products *MedicalNational General Group Number *National Plan Administrators Products *Membership FeesNational Plan Administrators Group Number *National Vision Administrators (NVA) Products *VisionNational Vision Administrators (NVA) Group Number *Nationwide Products *DentalPet InsuranceNationwide Group Number *New Benefits Products *Basic Health CareIdentity Theft Protection Featuring Legal ServiceMeMD TeledocNew Benefits Group Number *New Life Era Products *AccidentHospitalNew Life Era Group Number *One America Products *Group Term LifeGroup Term Life - ChildrenGroup Term Life - SpouseSTDOne America Group Number *Options Plus Products *MEC PlanOptions 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 BenefitsPet InsurancePet Benefit Solutions Group Number *Pinnacle Care Products *Medical ReviewPinnacle Care Group Number *Presidential Life Products *AccidentCancerCritical IllnessHospital IndemnityLifeShort Term DisabilityPrincipal Products *DentalVisionPrincipal Group Number *Profit Forward LLC Products *AFLACAllstate BenefitsAmFirstGuardianTrustmarkProfit Forward LLC Group Number *Regional Care Products *GLIADV2LRGDENTALMECBASICMECPLUSADVNOMECVSPPLANRegional Care Group Number *Reliance Matrix Products *GL Supplemental LifeLong Term CareShort Term DisabilityTerm LifeVAI AccidentVAR AD&DVCI Critical IllnessVHI HospitalVPL Long Term DisabilityVPS Short Term DisabilityReliance Matrix Group Number *Reliance Standard Life Products *DentalVisionReliance Standard Life Group Number *S&S Health Products *3500 HSA3500 PPO5000 HSA5000 PPOIHP BasicIHP MEC 1IHP MEC 2IHP PlusIHP PremierIHP UltimateIHP Ultimate Plan $5K HSAPrimarySelectSelect 1500 PPOSelect 2500 PPOSelect 3500 PPOSelect 6500 HDHPSelf-funded MedicalWellSelectS&S Health Group Number *SBMA Health Products *Anthem VisionBasic MEC + TEB Opt 1Beazley DeluxeBeazley Standard PackageDelta 1000 PlanDelta Comprehensive DentalDelta DentalDelta High Opt 1500Delta Preventive DentalDelta Preventive PlanEliteCare MECMECMEC BasicMEC PlusMET Advantage PackMET Term LifeMET VisionMeMD TeledocOptimaCareOptions Plus VSPPrimeCare MECProtection PackProtection Pack PlusUlt MEC + TEB Opt 2Ultimate MECUltra MECVSP 130 PlanVSP VisionSBMA Health Group Number *SEDERA Products *MEDICALSEDERA Group Number *Sun Life Products *AD&DAccidentCancerCritical IllnessDentalHospitalLTDLifeSTDVisionSun Life Group Number *Teladoc Products *TelehealthTeladoc Group Number *The Hartford Products *GTLLTDThe Hartford Group Number *The Standard Products *AccidentCritical IllnessHospitalSTDThe Standard Group Number *Transamerica (TEB) Products *AccidentCTLICancerCritical IllnessDisabilityHospital IndemnityLimited MedicalPermanent LifeTermTerm - SpouseUniversal LifeWhole LifeTransamerica (TEB) Group Number *UHC Global Products *DentalMedicalVisionUHC Global Group Number *UNUM Products *AD&DAccidentCritical IllnessHospitalLTDLifeSTDUNUM Group Number *US Legal Products *CDL DefenderFamily DefenderFamily Pro DriverUS Legal Group Number *United Healthcare Products *DentalMedicalVisionUnited Healthcare Group Number *United Way Products *DonationUnited Way Group Number *VSP Products *CareCare VisionVisionVSP Group Number *Vault Products *Healthcare Benefit PackageMedicalVault Group Number *Voya Products *AccidentCritical IllnessVoya Group Number *Washington National Products *AccidentCancerCritical IllnessHospitalUniversal LifeWashington National Group Number *WellFleet Products *AccidentCritical IllnessSTDShort Term DisabilityWellFleet Group Number *Zurich (AFLAC) Products *LifeZurich (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 formPreviousSubmit
