NASU Group Setup

Account Set Up Form

CASE Program
- Company Name:
- Corporate Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Preferred Contact @ Employer Group
  
  First NameLast Name
- Title
- Phone Number
  
  Area CodePhone Number
- Email
  example@example.com
- Additional DBA's that may be used to identify your organization:
- Number of Benefit Eligible Employees
- Number of Benefit Eligible Employees (64+)
- CASE Effective Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Please list additional locations:
- Anything you would like to share with TBG to assist with launching your account?
- Open Enrollment Dates/Month
- Plan Year Effective Date
- Are all your prescription drug plans creditable?
- Do you allow domestic partners?
- When does medical coverage end? (Last day of work, End of month, Other: please specify)
- Please select:
  
  Other
- Benefit Plan Options:
  
  Other
- How many plan options do you offer?
- Average employer cost for covering an employee 65+ (includes premiums+ claims)
- Please upload plan documents
  
  Browse Files
  Benefits Guide, SBC's, Employee Contribution Rates, Cobra Rates Cancelof
- Do you offer an HSA
- How (or to whom) does an employee submit a Medicare CMS-L564 (Verification of Coverage) form?
- Contact for Cobra Administrator
- Do you offer Retiree Benefits?
- Additional Group: Contacts
- Consultant Firm:
- Consultant Point of Contact:
  
  First NameLast Name
- Consultant Email
  example@example.com
- Consultant Phone Number
  
  Area CodePhone Number
- Additional Consultant Contacts
- Program Selection- Choose one
  prevnext( X )
  
  Under 800 Employees$400.00
  Ongoing Monthly Fee
  
  Quantity
  
  Over 800 Employees$0.50
  Ongoing Monthly Fee
  
  Number of Benefit Elig Employees
  Item subtotal:$0.00
  
  Implementation Fee$1,750.00
  One-time fee
  
  Quantity
  
  Total $0.00
- Preferred Invoice Recipient(s)
- Once this form is received, an invoice will populate and send electronically.
  
  I agree to the terms outlined and confirm that all provided information is true and accurate, should company or contact information change it is the sole responsibility of the company to notify Transitions Benefit Group with updated contact information.
- Signature
- Person Completing Form:
  
  First NameLast Name
- Title
- Company
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Account Set Up Form

Program Selection- Choose one