Quote Request Complete the form below to request a quote for Online Enrollment and/or Benefits Administration. Who is completing this form?Name* First Last Organization* Email* Phone*Who should the quote be sent to?Should the quote be sent to the person completing this form?* Yes No Name of Person who should receive quote* First Last Email of Person who should receive quote* Phone of Person who should receive quote*Prospect/Customer InformationProspect/Customer Organization Name* Benefits Administration InformationWhat type of enrollment(s) should be quoted?* Select All Selerix Annual Enrollment ONLY Selerix Annual Enrollment PLUS Ongoing Ben Admin Enrollment Essentials If quoting Selerix, which instance will be used?* No carrier partner USAble Trustmark Not quoting Selerix Total Number of Benefits Eligible Employees* Desired Enrollment Start Date MM slash DD slash YYYY Case Set-up DetailsPlease provide the estimated counts as directed below. Set-up fees will apply for changes made to these estimates after initial set-up. If a carrier partner is responsible for building certain products DO NOT include them in the counts below.Plan Set-upProvide the number of plans for each benefit type. Example: a dental plan with a high/low option would count as 2 plans.MedicalDentalVisionAncillary/Voluntary Rate SetsProvide the number of rate sets for each benefit type. Example: if the group has 3 classes of employees and 2 dental plans, that's 6 total rate sets.MedicalDentalVisionAncillary/Voluntary EDI/Import FormatsProvide the number of formats for each benefit type. If you only need the standard report format and nothing customized, enter 0.MedicalDentalVisionAncillary/Voluntary EDI/Export FormatsProvide the number of formats for each benefit type. If you only need the standard report format and nothing customized, enter 0.MedicalDentalVisionAncillary/Voluntary FormsProvide the number of forms for each benefit type. Forms are custom presentations needed inside of the enrollment system. This is rarely used.MedicalDentalVisionAncillary/Voluntary Enrollment NotesWhat else should we know about this enrollment? For example, will a carrier partner be responsible for building some of the products?CAPTCHACommentsThis field is for validation purposes and should be left unchanged.