New or Renewal Case Agreement

New or Renewal Case Agreement
Case Name*
Is this a new case for Velocity Benefits or an existing one?*

A new caseAn existing case
Broker Name*

First NameLast Name
Broker Rep Email*
example@example.com
Case Effective Date*

MonthDayYear
Date
Number of Eligible Employees*
Who is your Velocity point of contact?
Velocity Services Needed (Select one of the Below)

Package 1 - Communication - Text Messaging to Employees and Video CreationPackage 2 - Case Build - Employee Navigator Case Build, Open Enrollment Only, No File FeedsPackage 3 - HRIS/Ongoing Benefits Administration - Employee Navigator Case Build, Data Exchange file feeds are included (True EDI is not Included - EDI is typically required with Medical, Dental and Vision Carriers) For a list of Data Exchange Carriers and EDI Carriers visit: https://employeenavigator.com/marketplace/Package 4 - Telephonic Enrollment Support
For Package 4 and/or 5, will Employee Navigator be used?*
What platform will be used?*
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. *
Will you be using Employee Navigator as an ongoing benefits administration tool?
Desired Case Start Date*

MonthDayYear
Date
Projected End Date*

MonthDayYear
Date
How will you be funding this case?*

GA Override or Tech SubsidyFee BasedWorksite Split
Are you using one or more of our preferred carrier partners where we will be given a GA, MGA or Tech Subsidy?*

AflacAllStateArgusCompanion LifeEquitableGuardianHealth Benefit AllianceImagine360OneAmericaPrincipalSimple BenefitsSun LifeUnited HealthcareWellfleetOther - Not listed
If Other - Please Enter Carrier Name
Please Select The Plans Being Split or Overridden By

MedicalDentalVisionBasic LifeVol LifeShort-Term DisabilityLong-Term DisabilityAccidentCritical IllnessCancerHospital IndemnityPermanent Life InsuranceOther
Worksite Split Agreement (Broker/Velocity - What Is The Agreed To Split)
Fee Based Per Employee Per Month Charge
Flat Fee
Case Add-Ons Needed?

True EDI (Typically on medical carriers) - $1,000 + $1 PEPMPayroll Integration - $500 (Waived for Payroll Partners)File Feed for Non-Partner Carriers - $500Onboarding and Tasks setup by the Velocity Team - $500New Hire Enrollment - Ask for a Quote
Case Add-Ons Needed for your renewal?

True EDI (Typically on medical carriers) - $1,000 with plan changes + $1 PEPMTrue EDI (Typically on medical carriers) - $500 with no plan changesPayroll Integration - $500File Feed for Non-Partner Carriers - $500Onboarding and Tasks setup by the Velocity Team - $500New Hire Enrollment - Ask for a Quote
If the case is fee based or if you are wanting the case add-ons then we will need the name and email address of whom we should be invoicing. Please provide below.*
Any additional Case Notes
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*

MonthDayYear
Date
Submitter Name*

First NameLast Name
Submitter Signature*

Clear
Should be Empty:

New or Renewal Case Agreement

Scope of Work