Benezon LLC | New Group Implementation Form

1Group Information

2Agency Information

3Policy Information

4Greeting / Required Docs

Agency Information
Agency Name
Agency Contact Name
First Last
Agency Address
Street Address Address Line 2 City State ZIP Code
Agency Contact Email
Agency Contact Phone
Agency Branding
Agency Logo
Accepted file types: jpg, png, Max. file size: 50 MB.
Please submit a high-resolution logo in JPG or PNG format.
Flier Request Date
MM slash DD slash YYYY
Implementation: Agency Contact
Name
First Last
Title
Email
Phone
Billing: Agency Contact
Name
First Last
Title
Email
Phone
Billing Type/Options
- Agency Master Bill (Billed at Net Cost – No Billing Fee)
- Third Party Billing (TPA, etc. – Billed at: Net Cost – No Billing Fee)
- Direct Group Billing (Billed at Net Cost – plus Direct Billing Fee*)
* Direct Billing is a service provided as a convenience to our Clients. There is an administrative fee of $0.25 pepm per each group with a $50.00 cap and a $10.00 minimum. Direct Billing Fees are retained from rates marked up to the Group. In cases where there is no mark up (Groups are billed at Net Cost), Benezon will invoice the agency the Direct Billing Fee.
Enter the Direct Billing Rate (including Mark-Up)
Third Party Name
Group Contact Name
TPA Name
Group Contact Email
TPA Email
Renewals: Agency Contact
Name
First Last
Title
Email
Phone
Daily Service: Agency Contact
Name
First Last
Title
Email
Phone

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Desired IVR Greeting/Options
How many transfer options do you want your line to have?
Please enter a number from 1 to 4.
Please indicate your selections below. Note that if you selected more than one , advocacy must be one of your selections. If any of these options require an external transfer, please indicate the appropriate number.

Option 1: Advocacy
Number (if external transfer)
Option 2
Number (if external transfer)
Option 3
Number (if external transfer)
Option 4
Number (if external transfer)
How should we refer your line?
Examples include “The XYZ Concierge Line.” “The ABC Advocacy Line,” “The GHI Advocacy Line, Powered by _____”
Required Documents
Required Documents include:
1. Participating Employee Census (aka eligibility file)
NOTE: If you do not have this handy, please click the "Save and Continue Later" link below so the information you've entered so far is not lost. You may then come back and finish submitting your form as convenient.
Required Documents include:
1. Participating Employee Census (aka eligibility file)
2. Benefit Info (SBC)
3. Plan Summary
4. Benefit Guide
NOTE: If you do not have any of these handy, please click the "Save and Continue Later" link below so the information you've entered so far is not lost. You may then come back and finish submitting your form as convenient.
Eligibility File (required)
Download a sample eligibility form (Excel format)
Drop files here or

Accepted file types: xls, xlsx, csv, Max. file size: 50 MB, Max. files: 1.
Additional Required Files
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 50 MB.
These documents are required to setup your account. Please provide as many as possible at this time. We would be glad to use HR Benefit Portal for required documentation (such as Employee Navigator, Bernie Portal, or Employeease, etc.)
Additional Notes
If using a HR Benefit Portal, please provide URL, username and password.
File
Max. file size: 50 MB.

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New Group Implementation

Group Name & Contact Information

Agency Information

Implementation: Agency Contact

Billing: Agency Contact

Renewals: Agency Contact

Daily Service: Agency Contact

Desired IVR Greeting/Options

Required Documents