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Insurance products and services are offered or issued by Transamerica Life Insurance Company, Cedar Rapids, IA; Transamerica Financial Life Insurance Company, Harrison, NY (licensed in New York); Transamerica Premier Life Insurance Company, Cedar Rapids, IA; and Transamerica Casualty Insurance Company, Columbus, OH. Variable products and mutual funds are underwritten and distributed by Transamerica Capital, Inc., or Transamerica Investors Securities Corporation, each a broker/dealer and member of FINRA Securities and investment advisory services offered by Transamerica Financial Advisors, Inc., a broker/dealer, member of FINRA, SIPC and a Registered Investment Adviser. Investment advisory services focused on the unique needs of individual retirees, retirement plans and their participants offered by Transamerica Retirement Advisors, LLC, a Registered Investment Adviser. References to Transamerica on this site apply to an individual company or collectively to these and other Transamerica companies. This site may not yet be approved by the Departments of Insurance in all states at the time of publication. Transamerica companies are part of the Aegon Group. Copyright 2011 - 2020 Transamerica Corporation, 6400 C St SW Cedar Rapids, IA 52499—All Rights Reserved

258525

Tracking Number:
Submitter Name: *
Submitter E-mail: *
Submitter Phone: *
Additional Confirmation Recipients:


Who should be contacted regarding this case?*
Other Contact Name: *
Other Contact E-mail: *
Other Contact Phone: *
Are you the Regional Vice-President? *	Yes No
Please select an option: *

Employer Name: *
# of Eligible Lives: *	3 - 100 Eligible Employees 101 – 249 Eligible Employees 250 - 1,999 Eligible Employees 2,000+ Eligible Employees
Products: *	AccidentAdvance AccidentAdvance – Self Admin Accident 11 AccidentSelect Claims Minder Claims Notification CriticalEvents CriticalEvents – Self Admin Critical Illness 12 CriticalAssistance Advance CriticalAssistance Plus CriticalAssistance Select CancerSelect Plus DRMS Administered Group Short Term Disability DRMS Administered Group Long Term Disability Group Term Life Hospital Select III Hospital Select – Self Admin Hospital Select II – New Hires Only Provider Select TransConnect – AMWINS Administered Executive Health TransConnect – TEB Administered TransDI Plus – Transamerica STD Income Select – FL Domiciled TransElite – Universal Life Trans Select – 5 year Trans Select – 10 year Trans Select – 20 year Trans$ure – Whole Life UL10 – Universal Life ISWL – Whole Life
Employer Group Number: *

# of Eligible EE: *
Regional Vice-President:
Domicile State of Group:
Is this a retirement referral or cross sell opportunity?: *	Yes No
Are there any exceptions on this case?: *	Yes No
Exception Documents: *
New or Re-Enroll: *
Projected Premium: *

Are Commissions to be paid as currently on file?: *	Yes No
Updated Agent Commission Form: *
Agent Commission Form

What type of enrollment are you submitting?: *
Products: *	AccidentAdvance AccidentAdvance – Self Admin Accident 11 AccidentSelect Claims Minder Claims Notification CriticalEvents CriticalEvents – Self Admin Critical Illness 12 CriticalAssistance Advance CriticalAssistance Plus CriticalAssistance Select CancerSelect Plus DRMS Administered Group Short Term Disability DRMS Administered Group Long Term Disability Group Term Life Hospital Select III Hospital Select – Self Admin Hospital Select II – New Hires Only Provider Select TransConnect – AMWINS Administered Executive Health TransConnect – TEB Administered TransDI Plus – Transamerica STD Income Select – FL Domiciled TransElite – Universal Life Trans Select – 5 year Trans Select – 10 year Trans Select – 20 year Trans$ure – Whole Life UL10 – Universal Life ISWL – Whole Life
Number of applications?: *
Paper Application(s): *
New Hires Only Enrollment Spreadsheet or File: *
Annual Enrollment Spreadsheet or File: *

Broker or Writing Agent Name: *
Broker or Writing Agent currently appointed?: *	Yes No
Enrollment Firm Name: *
Enrollment Firm currently appointed?: *	Yes No

Implementation Contact Name: *
Implementation Contact Email: *
Implementation Contact Phone: *

Enrollment Strategy: *	Face to Face Call Center Self-Enroll
Enrollment Platform: *	Paper Apps Electronic Enrollment Spreadsheet Enrollment Web Portal Enroll

Enrollment Platform Vendor: *
Vendor Contact Name: *
Vendor Contact Email: *
Vendor Contact Phone: *

Are you transferring to AmWins administration?:	Yes No
WeCare Spreadsheet:	Download WeCare Spreadsheet

	If terminating coverage, please select the products to be terminated in the list below
Products To Terminate:*
TransConnect Renewal Form: *

# of employees covered under underlying medical plan:
Employees eligible for the TransConnect Benefit:
Underlying Plan Waiting Period:
Employer Paid:	Percentage Amount $ %

Is this a Takeover group that has been approved by Transamerica Underwriting?: *	Yes No
Takeover Underwriting Approval: *
Takeover Billing Invoice: *
Underwriting Offer?: *	Standard Special UW Offer
Is this employer going to Self-Administer their bill? : *	Yes No
Special UW Offer: *
Do You have a Billing Worksheet?:*	Yes No
Billing Worksheet:

Are Commissions to be paid as they are currently contracted on record?: *	Yes No
Agent Commission Form
Updated Agent Commission Form: *

Are all enrollers listed on the Agent Commission Form: *	Yes No
Upload list of enrollers: *
Do you need marketing materials? *	Yes No
TransApp, Selerix, Common Census or Other: *	TransApp Selerix Common Census Other

Enrollment Start Date: *
Enrollment End Date: *

Medical Plan Summary :
Rates:
List Bill:
Binder Check:

Selerix Case Builder Contact Name: *
Selerix Case Builder Contact Email: *
Selerix Case Builder Contact Phone: *

Enrollment Platform Vendor Information: *
Enrollment Platform Vendor: *
Vendor Contact Name: *
Vendor Contact Email: *
Vendor Contact Phone: *

Signed Employer App:*
Agent Commission Form:*
Agent Commission Form
Sold Proposal(s) & Rate Sheets for Life Products:*