Marketing Forms
Marketing Requests
Enrollment Promotion
OE Materials Request Form
Marketing materials for employee enrollment
Company
EBI
JTS
CES
Contact Email:
(Required)
Please enter your work email address.
Renewal or New Client
(Required)
Renewal
New
Employer Name
(Required)
Are you using a BenAdmin system?
(Required)
Yes
No
BenAdmin System
(Required)
Employee Navigator
Selerix
Other, please specify below
None
Online Enrollment Link
If using another BenAdmin, please provide an enrollment link.
Open Enrollment Dates
Enrollment Type
(Required)
Choose all that apply
In-Person
Self-Enrollment
Call Center
Enrollment START Date
(Required)
MM slash DD slash YYYY
Enrollment END Date
(Required)
MM slash DD slash YYYY
Shared Enrollment Dates? – Self-Enrollment
Are SELF-ENROLLMENT dates the same as in-person?
Yes
No
Self-Enrollment START Date
MM slash DD slash YYYY
Self-Enrollment END Date
MM slash DD slash YYYY
Shared Enrollment Dates? – Call Center
Are CALL CENTER dates the same as in-person?
Yes
No
Call Center START Date
MM slash DD slash YYYY
Call Center END Date
MM slash DD slash YYYY
Booking Link or Call Center Number
Enrollment Materials
Materials Needed
(Required)
Landing Page
Booklet
OE Email
OE Print Flyer (8.5×11)
Poster
Group Presentation
Master Bookler
CES with Chubb
CES No Chubb
AEA with Chubb
AEA no Chubb
Landing Page Link
Product List
Medical
Dental
Vision
Accident
Basic Group life w/ ad&d
Cancer
Critical illness
Dependent Care
Disability -Long Term
Disability – Short Term
EAP
FSA
Heuro
Hospital Indemnity
HRA
HSA
Identify Theft
Life Insurance
Pet Insurance
Retirement Services
SHARx
SimpleWill
SOLA
Number of Enrollers
So we can provide every enroller with a laptop billboard promoting the hub.
Number of Sites
So we can provide a leave-behind poster for each break room.
Booklet Request
Print
Flipbook
Both
Quantity of Print Booklets
(Required)
Quantity of OE Print Flyer
(Required)
Quantity of Poster
(Required)
Mail or Pickup?
(Required)
Mail
Pickup
Mail AND Pickup
Quanity for Pickup
Quantity for Mail
Date mailed booklets must arrive by
(Required)
MM slash DD slash YYYY
Business Name (if applicable)
Contact Name
(Required)
Contact Phone
(Required)
Mail to Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date required to be in pickup area by
(Required)
MM slash DD slash YYYY
Include Site Schedule?
Yes
No
Site Schedule
If there are multiple dates, times, and locations, please list them below.
Date
Time
Location
Add
Remove
Uploads
Share supporting files here.
Max. file size: 1 GB.
HSA: Vendor
HSA: Employee's MAX Contribution
IRS Maximum
Other
Employer Contributing?
Enter the annual contribution amount per participant.
Employee's Reduced Maximum
FSA: Vendor
Plan Year Start Date
MM slash DD slash YYYY
End of Plan Year Options
Grace Period
Runout
FSA: Run-out (claims submission) period after grace
90 Days
Other
FSA: Other Number of Run-out days
FSA: Employee's MAX Contribution
IRS Maximum
Other
Employee's Reduced Maximum
FSA: Carryover (Rollover)
Full IRS Maximum
Other
FSA: Other Carryover (Rollover)
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