Benefit Design Group

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New Group Information Form

For Groups 1-50 Eligible Employees Only
*These fields are required.

*Account Name:
*Account Address:

*Telephone Number:	e.g. 555 445-5555
Fax Number:	e.g. 555 445-5555
Email Address :
Nature of Business:
SIC Code (if known):
*Federal Tax ID:
President/Owner:
*Contact Person:

Waiting Period for New Hire:

*1st of the month following: (check one)

date of hire	30 days	60 days
90 days	6 months	1 year
Other

Prior Group Carrier:

Contribution Formula:

% Employer

% Employee

*Number Eligible:

*Plan Effective Date:

Check #:

Check Amount:

Contact Person's Title:

Coverage Breakdown of Contracts
	Single
	Parent/Child
	Parent/Children
	Husband/Wife
	Family
	Total Enrolled

Quarterly Wage & Tax Report (DLLR/OUI 16) Breakdown
	*Full-Time Employees
	*Part-Time and Seasonal Employees
	*Waivers
	Terminated
	*Total that appear on report
	Enrolled but do not appear on report

Special Notes or Comments:

Commision Agent/%:
*Sub Agent Name:	*Date:	e.g. 02/14/2000
For Benefit Design Use:

Submission of this form will allow Benefit Design Group, LLC to process the information contained in this document. The Employer agrees to maintain a signed copy of this document. Benefit Design Group, LLC, reserves the right to request a copy of the signed document at any time from the Employer.



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