Pre-Enrollment Worksheet

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

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

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

MonthDayYear
Date
Enrollment Start Date*

MonthDayYear
Start Date
Enrollment End Date*

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

VideoBenefit SnapshotTextEmailNone 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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