Avance Intake Form

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Avance Intake Form

Please fill out the form below and we will contact you shortly

Name of Account *

Employer Contact Name and Title *

Employer phone number *

Employer E-mail *

Name of Broker

Broker Phone #

Broker E-mail Address

Name of Avance Sales Director *

Requested Effective Date *

Requested Enrollment Date *

Carrier (if undecided, please type "undecided")

Method of Enrollment *

Face-to-face, call center etc.

Products to be offered *

Critical Illness

Short Term Disability

Accident

Hospital Indemnity

Cancer

Long Term Disability

Term Life

Permanent Life

NONE, Avance products only

Other:

Required

Number of Eligible EE'S *

Number of locations *

Any languages other than english? (please include on the census)

# of EEs at each location (best to use a census)

Existing Technology Platform

Will you be using N-GAGE'S VB Platform *

Our VB Platform is available at no charge. This includes VB products, ongoing EDI Feeds to carrier and EDI for payroll

Yes

Would you like a quote on any additional services

Core Benefit Build Out

Electronic Employee onboarding (W-4, I-9 etc)

Dependent Eligibility and Verification

Other:

Access to N-GAGE'S Online Employee Scheduler

Available at no charge

Yes

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Other Notes

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