Case Prospect Form

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Case Information

Group Legal Name *

Number of Eligible Lives *

Anticipated Effective Date *

Anticipated Enrollment Start Date *

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Group Type *

Billing Frequency

Group Situs State *

Do you intend to utilize a platform?

Do you know the carrier(s) you intend to use?

Have any carriers declined this case?

What specific products or services has the client requested?

Name of AIC Consultant you are working with:

Please describe any unique needs or challenges of this case.

Agent/Rep Contact Information

Name *

First

Last

Email *

Phone *

Organization *

Which best describes your current role? *

Employer or HR assistant/executive
Carrier or Union Rep
Agent or Broker
Other

Case Information

Group Legal Name *

Number of Eligible Lives *

Anticipated Effective Date *

Anticipated Enrollment Start Date *

Group Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Group Type *

Billing Frequency

Group Situs State *

Do you intend to utilize a platform?

Do you know the carrier(s) you intend to use?

Have any carriers declined this case?

What specific products or services has the client requested?

Name of AIC Consultant you are working with:

Please describe any unique needs or challenges of this case.

Agent/Rep Contact Information

Case Information

Phone

Email

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Agent/Rep Contact Information

Case Information