New ESC Implementation Launch Form

Required fields are designated with an *

*Company Name:

*IAG Representative:

*IAG Representative Email:

*Requested Go Live/Open Enrollment Date:

*Company ESC Main Contact:

*Company ESC Main Contact Email:

*Company ESC Main Contact Phone:

*Does client require an existing employee import? Select Option Yes No

*Product Choice Select Option Flexible StaffCARE Essential StaffCARE

*Plans Offered:

*Where should data files be sent to? Select Option ePortal ESC customer using Essential Client FSC customer using Essential Client

*If this is an Essential Client, what is the plan type? Select Option Plan 1 Plan 2 Plan 3 Plan 4 Value Plan N/A

*File Name:

*Enrollment Start Date:

*Enrollment End Date:

*Group Number:

*Indemnity Plan Number:

*MEC Plan Number:

*MVP Customer/Product Number:

*Tier Selection Select Option Three Four

*Offering Configuration (Fixed Indeminity/Ancillary) Select Option Bi-Weekly Monthly Semi-Monthly Weekly

*Are Ancillary Products Offered as a Bundle or Individually? Select Option Bundled Individually

*Offering Configuration (MEC) Select Option Bi-Weekly Monthly Weekly

*Are employees able to elect ancillary products if Fixed Indemnity is declined? Select Option Yes No

*Ancillary Products Offered

Vision

Dental

Short Term Disability

Term Life

Critical Illness

Accident

Submit