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My Benefits Channel

My Benefits Channel

Streamline the Employee Life Cycle

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Quote Request

Complete the form below to request a quote for Online Enrollment and/or Benefits Administration.

This field is for validation purposes and should be left unchanged.

Who is completing this form?

Name*

Who should the quote be sent to?

Should the quote be sent to the person completing this form?*
Name of Person who should receive quote*

Prospect/Customer Information

Benefits Administration Information

What type of enrollment(s) should be quoted?*
If quoting Selerix, which instance will be used?*

Case Set-up Details

Please 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-up
Provide the number of plans for each benefit type. Example: a dental plan with a high/low option would count as 2 plans.
Medical
Dental
Vision
Ancillary/Voluntary
 
Rate Sets
Provide 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.
Medical
Dental
Vision
Ancillary/Voluntary
 
EDI/Import Formats
Provide the number of formats for each benefit type. If you only need the standard report format and nothing customized, enter 0.
Medical
Dental
Vision
Ancillary/Voluntary
 
EDI/Export Formats
Provide the number of formats for each benefit type. If you only need the standard report format and nothing customized, enter 0.
Medical
Dental
Vision
Ancillary/Voluntary
 
Forms
Provide the number of forms for each benefit type. Forms are custom presentations needed inside of the enrollment system. This is rarely used.
Medical
Dental
Vision
Ancillary/Voluntary
 
What else should we know about this enrollment? For example, will a carrier partner be responsible for building some of the products?
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