Pre-Enrollment Worksheet

Pre-Enrollment Worksheet
Case Name *
Broker or Agent Name *

First Name Last Name
Broker or Agent Email *
example@example.com
Velocity Rep Name *

First Name Last Name
State of Case *
Employee Count *
Number of Locations *
Effective Date *

Month Day Year
Date
Enrollment Start Date *

Month Day Year
Start Date
Enrollment End Date *

Month Day Year
End Date
Which Technology (if applicable) *
What Pre-enrollment Communication is Velocity providing? *

Video Benefit Snapshot Text Email None Needed
Method of Communication *
If you are wanting call center enrollment - what hours do you prefer (not guaranteed but we will do our best to accommodate)? *
Bilingual Counselors Needed? *
What Language? *
Face to Face Details - How Many Locations? What States? Other Details: *
Will new ID cards be issued and for what products and when can employees expect to receive them? *
Who should employees contact throughout the year if they have benefit questions and what is their contact info? *
Do employees have to complete their enrollment if they wish to decline all coverage? *
Will coverage remain the same (rollover) if they do not complete their enrollment? *
Is the company trying to drive participation to a specific product (HDHP, HSA, ETC)? *
If certain lines of coverage are changing carriers, will any of the old policies with the former carrier still be payroll deducted? *
Other information we should know about the Group? For example: Carrier Challenges, Key Employee Turnover, Deductible Going Up, Jump in Medical Rates, Merger, Operates Under Different Names in Various Locations. *
Add any applicable files for benefits counselors to reference (Benefit Guides, PPT Presentations, Notes, Plan Docs if they have not been submitted somewhere else).

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