Link Benefits New Business Intake Form

New Business Intake Form

- PLEASE REVIEW -

Note for agents: You will need information from your company contact to complete this form. It is encouraged to gather the required documents, then review this form with the client to complete in the most efficient fashion. Reviewing together over a call or screen share is often the most effieicent way to complete this form.

For Priority Health Business:

A list of required, but commonly missed items to successfully fill this form is available HERE

Please note this list is not exhaustive

Additional documents for signature: Depending on products sold, additional documents for signature may be generated to fufill carrier requirements. If you are selling Priority Health, keep an eye out as there will be at least one additional document requiring signature once this form has been completed.

These documents are circulated electronically and will be sent directly to your and/or your client's email. There will be an email for each document requiring a signature.

For ancillary coverage placements: We will follow the carrier's preferred onboarding process. The information provided in this form will be delivered to the appropriate onbarding teams upon completion.

For benefit administration system builds: If requesting a benefit administration build out or revision, there will be a second form sent when this submission is received and reviewed. This form will only request information not provided below and will prefill many datapoints already gathered in this form. The agent will receive a separate prompt via email to complete the build form.
Agent & Agency Information
Agent Name*

First NameLast Name
Agency Name*
Agent/Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Agent Email*
example@example.com
Agent Phone*
Please enter a valid phone number.Format: (000) 000-0000.

Company Information

Please note: If you'd like to move on to the next page without a required answer, you may enter a placeholder. Just remember to come back and enter the true value, once determined!
Company Legal Name*
Company Structure*
YesNo
YesNo
Company Address*

Street Address

Street Address Line 2

CityState

Zip Code
Yes
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
Company TIN*
Total Number of Employees*
Includes all employees; full-time, part-time, seasonal, and variable hour employees
Number Full-time Equivalent Employees*
Calculate the number of Full-time Equivalent Employees (FTEs)
Number of Eligible Employees*
Effective Date of Coverage*

MonthDayYear
Current Date

MonthDayYear
Date
Lead Time

Group Contact Information

Please note: If you'd like to move on to the next page without a required answer, you may enter a placeholder. Just remember to come back and enter the true value, once determined!
Admin Contact Name*

First NameLast Name
Admin Contact Email*
Admin Contact Phone Number*
Format: (000) 000-0000.
Billing Contact Name*

First NameLast Name
Billing Contact Email*
Billing Contact Phone Number*
Format: (000) 000-0000.
President / CEO Full Name*

First NameLast Name

Priority Health

Fully Funded Small Group New Business
2-50 ACA Medical Plan Selections
Select sold medical plans below*

Priority Health

Fully Funded Small Group New Business
Additional Coverage Information
YesNo
Previous group number*
Name of most recent medical insurance carrier*
Workers’ compensation carrier*
Workers’ compensation policy #*
YesNo

Priority Health

Fully Funded Small Group New Business
Administration Solutions
YesNo
YesNo
YesNo
YesNo

Priority Health

Fully Funded Small Group New Business
Documentation & Attestation
PLEASE NOTE: PLACEHOLDER DOCUMENTS NOT ACCEPTED! Please revisit this form at a later date if you do not have all required documents. You can save your progress by clicking the save button at the bottom of the page and return via the emailed link once all required information is obtained.
Upload W9*

Cancelof
Upload UIA 1028*

Indicate on the UIA 1028 form if an employee is terminated, part-time or otherwise ineligible for coverage
Cancelof
YesNo
OPTIONAL: Upload Voided Check (if ACH auto-pay is desired)

Cancelof
Sole Proprietor: Upload Schedule C & Copy of Federal Tax ID Verification*

Cancelof
Partnership: Upload Schedule 1120 & Articles of Incorporation or federal doc w/ FEID*

Cancelof
Corporation: Upload Schedule 1120 & Articles of Incorporation or federal doc w/ FEID*

Cancelof
Farmer: Upload Schedule F*

Cancelof
Limited Liability Company: Upload Schedule 1065 & Articles of Organization*

Cancelof
Nonprofit: Upload IRS Verification Form and state licenseor certification and copy of applicable tax filing for entity*

Cancelof
Yes — If you met this threshold during the previous year or current calendar year, please provide the date that this threshold was reachedNo — Please enter today’s date
Date*

MonthDayYear
Date
Yes — Enter 1/1 of the previous calendar year dateNo — Please enter today’s date
Date*

MonthDayYear
Date
Yes — I already have purchased pediatric dental coverage through a certified stand-alone dental carrier.No — I do not currently have pediatric dental coverage, but understand this is a requirement and certify my intent to purchase this
Signature* (Agent of record signature is acceptable)
Authorized Signer Name*
Agent of record is acceptable
Authorized Signer Title*
Agent of record is acceptable
Signature Date*

MonthDayYear
Date

Census File Upload
Enrollment Census for Direct Submission to Carrier
- Employee first & last name
- Employee status (active, leave, etc.)
- Employee email address (important if using benadmin)
- Employee phone
- Gender
- Birth date
- Hire date
- Employment class (if applicable)
- Job title
- Annual salary -or- hourly wage
- Scheduled hours
- SSN
- Home address
  - Street address
  - City
  - State
  - Zip code
- Dependent names, genders, and birth dates
- Dependent relationships (spouse, domestic partner, child, etc.)
- Election for each member (enrolled or waived) for each plan
  - Election tier for dental, vision, accident etc.
  - Name of elected plan (if multiple options)
  - Volumes for voluntary benefits (vol. life, critical illness, vol. disability,etc.)
  - Benefit class (if applicable)
- Effective date of coverage
The Priority Health enrollment census template can be downloaded HERE.
Direct Submission Census Upload*

Cancelof
Census will be emailed at a later date

Paper Form Enrollment
Upload Employee Enrollment Forms Below*

Please note that for employees that are not enrolling and are otherwise eligible for benefits, please indicate a waiver reason on the UIA 1028 form. Waiver forms are also permitted.
Cancelof
Forms will be emailed at a later date

Submit Application
Please add any additional details not previously requested in the intake form
Should be Empty:

Agent & Agency Information

Company Information

Group Contact Information

Carrier & Plan Selection

Eligibility Provisions

2-50 ACA Medical Plan Selections

Additional Coverage Information

Administration Solutions

Documentation & Attestation

Census File Upload

Paper Form Enrollment

Submit Application