• New or Renewal Case Agreement

  • Is this a new case for Velocity Benefits or an existing one?*
  • Case Effective Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Velocity Services Needed (Select one of the Below)

  • Scope of Work

    Velocity Benefits encourages you to review our "Scope of Work" below.
  • Communication
  • Please initial that you have read the Communication Scope of Work and understand any additional rounds of communications would be .50 per employee per round of texts. Also, once a video is accepted as complete that any changes there after would incur a $100 per hour change fee.*
  • Technology
  • Please initial that you have read the Technology Scope of Work and understand that once a case is built and reviewed by the broker team as being complete and ready to launch, that any changes there after would incur a $100 per hour fee change fee.*
  • Enrollment (Education)
  • Please initial that you have read the Enrollment Scope of Work and that you understand that Velocity required 70% of the population enroll with an enroller for face to face enrollments. If this requirement is not met then the broker will be charged for the cost of the enroller for that day as well as travel costs of getting that enroller there. *
  • Desired Case Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Projected End Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • How will you be funding this case?*
  • Are you using one or more of our preferred carrier partners where we will be given a GA, MGA or Tech Subsidy?*
  • Please Select The Plans Being Split or Overridden By
  • Case Add-Ons Needed?
  • Case Add-Ons Needed for your renewal?

  • We agree to partner in good faith to make the enrollment a positive experience for everyone involved.  Velocity commits that if, for some reason, that either party desides to no longer partner together that they will release all data back to the broker and their client with 10 business days.  At that point Velocity commits to deleting all person and company info of the former client. 

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: