OneSite Intake Form - Web Benefits Design Corporation

Overview

Onesite is a single source solution to help employers manage their overall benefits administration needs. It provides administration efficiencies, claim and eligibility support and member connectivity. One system. One team. One solution. Valuable Employee Benefits Services from Mutual of Omaha and Web Benefits Design.

General Contract Information

Contract Effective Date

Contract Duration (Months)

Contract Renewal Date

# of Enrollment Periods

Employer Information

Company Name *

Company Website

Primary Contact *

First

Last

Primary Contact Job Title

Contact Email *

Contact Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Has the client expressed interest in additional WBD products/services? (Select all that apply)

Broker Information

Does the client have a broker? *

Yes
No

Deal Details

Target Go-Live Date

Plan Effective Date

Open Enrollment Start Date

Open Enrollment End Date

Using System for CY Benefits?

Yes
No

# of Benefits Eligible Employees

# of Non-Eligible Employees

Total Employee Count

SIGNATURE AND AUTHORIZATION

Name *

First

Last

Signature *

Please use your mouse to sign. If your device is touch screen enabled feel free to use your finger or a stylist

Date *

Terms and conditions ....... *

I accept the terms stated above