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?This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.CommentsThis field is for validation purposes and should be left unchanged.
