My Benefit Builder

GROUP APPLICATION

Broker Information

Representative ID *

Group Information

Group Name*

Estimate number of members *

Desired Start Date *

Group Type *

Federal Tax ID Number (TIN/EIN)*
*Social Security if Partnership

Group Industry *

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Group Contact Information

Group Contact First Name *

Group Contact Last Name *

Group changed Contact Title *

Email*

Mobile Phone Number *

Fax

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Group/Admin Login Information

Email (Username) *

Password *

Minimum 8 characters, at least one letter, one number & one special character

Re-Type Password *

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Group Address

Street Address

Apt/Suite/Other

City*

State*

Zip Code *

Continue without Address Validation

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Billing Address & Contact Information

Check this box if Employer/Group Address are the same.

First Name *

Last Name *

Street Address *

Apt/Suite/Other

City *

State *

Zip Code *

Email *

Mobile Phone Number *

Fax

Continue without Address Validation

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Payment Information

Payment Method *

EFT/ACH

If ACH, please complete the following: *

Routing Number

What is Routing Number ?

Bank Name

Account Number

Name on Bank Account

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Group Contribution

Yes

Group Defined Contribution Type

Flat Dollar Amount

Percentage

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Signature & Verification

Verification Code *

QUWP8

Verification Code *

Type your full name which will be your “signature” to verify application terms and agreement: *

Signature Date:

GROUP APPLICATION

Broker Information

Group Information

Group Contact Information

Group/Admin Login Information

Group Address

Billing Address & Contact Information

Payment Information

Group Contribution

Signature & Verification

Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 100,000 members.
Click here to Learn more

Questions? Call 866-201-7191 We're standing by to help you make the best decision.

GROUP APPLICATION

Broker Information

Group Information

Group Contact Information

Group/Admin Login Information

Group Address

Billing Address & Contact Information

Payment Information

Group Contribution

Signature & Verification

Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 100,000 members. Click here to Learn more

Questions? Call 866-201-7191 We're standing by to help you make the best decision.

Access to the insurance plans and large group pricing on this website is predicated upon joining Elevate Wellness, a national association with over 100,000 members.
Click here to Learn more