Who is completing this form?Name* First Last Organization* Email* Phone*Distribution Channel Partner Contact Person for ImplementationIs the DCP Contact for Implementation the same as the person completing this form?* Yes No Name of DCP Contact Person for Implementation* First Last Email of DCP Contact Person for Implementation* Phone of DCP Contact Person for Implementation*Include DCP Contact Person in communications with Customer re: Implementation?* Yes No Customer InformationThe Customer is a customer of Distribution Channel Partner known as follows:* Address* Street Address City State / Province / Region ZIP / Postal Code Customer Type* New MBC Customer Existing MBC Customer Total Number of Employees (Full-time + Part-time)* Agreement Effective Date* MM slash DD slash YYYY This should be the 1st of a monthSend Agreement for Signature to* First Last Email to Send Agreement to* Target Date for MBC Initial Contact to Customer* MM slash DD slash YYYY Payroll/HR Vendor InformationPayroll Vendor / Software Version Payroll/HR Functionality Currently Used Paystub eDelivery Paystub Viewing W-2 eDelivery W-2 Viewing Payroll/HR Functionality Details:Please describe the current payroll/HR functionality (e.g., vendor, capabilities, etc.)Other vendors currently usedOther vendors currently used: Benefits Administration InformationWill Customer be using Selerix for enrollment?* Yes, for annual enrollment only Yes, for ongoing ben admin No Carrier Partner for Selerix USAble Trustmark None Will MBC be responsible for building out the case in Selerix? Yes No, the carrier will build it out Enrollment Date MM slash DD slash YYYY Implement MBC before Enrollment? Yes No Enrollment NotesSelected MyBenefitsChannel AppsIn this section, please indicate the apps and services the customer wants to purchase NOW. You will have the opportunity to indicate what the customer is not purchasing, but is interested in learning more about later in the form.Benefits Package includes: Onboarding, Benefits, Wellness Essentials, Compliance (SaaS), Offboarding, and MyTaskManagerHR Package includes: Onboarding, HR, Training, Offboarding, and MyTaskManagerPremium Package includes the following modules: Onboarding, HR, Benefits, Wellness Essentials, Pay Stubs, Training, Compliance (SaaS), Offboarding, and MyTaskManagerBase Package Selected by Customer* Benefits Package HR Package Premium Package Add-on Apps and Services Selected by Customer*These are apps they ARE purchasing now. Select All Hiring Compliance Benefits & Wellness Time & Attendance None Hiring Add-on Apps and Services Selected by Customer Select All Applicant Tracking - Premium Assessment Module - 1 Assessment Assessment Module - All Assessments Dialogg Module Background Checks/Drug Screens Additional Career Sites (be sure to note how many) Compliance Add-on Apps and Services Selected by Customer Select All Total Care ACA IRS Reporting (Do It For You Solution) Total Care ACA VHE Tracking (Do It For You Solution) Total Care ACA IRS Reporting AND VHE Tracking (Do It For You Solution) Additional EINs for ACA (if more than 2, be sure to note how many) Benefits & Wellness Add-on Apps and Services Selected by Customer Select All Benefits Administration - Must be using approved vendor such as Selerix, requires Implementation Workbook to be completed by Customer and Partner Wellness - Customized Wellness Plan (requires collaboration in design with Partner) Wellness - Wellness Management Services (requires collaboration in design with Partner) Wellness - Telemedicine Equipment (requires custom quote) Time & Attendance Add-on Apps and Services Selected by Customer Time & Attendance Essentials Attendance On Demand (requires separate contract with 3rd party connector) Attendance On Demand Time Clocks (requires separate contract with 3rd party connector) If customer is choosing a Time & Attendance Add-on, how many employees will be using it?Customer Also Interested In...Add-on Apps and Services Customer is Interested In*These are apps they are NOT purchasing now, but would like to learn more about. Please provide detail below. Select All Hiring Compliance Benefits & Wellness Time & Attendance None Details about Apps and Services Customer is Interested inImplementation Contacts and InformationImplementation Contacts*Provide at least one customer contact for implementation. Add additional rows as necessary.NameTitleEmailApps Responsible for App Priority / Sequence NotesTiming of Implementation NotesSpecial ConsiderationsCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
