Implementation Plan For help with this form contact sales at (207) 865 6565 #3 or firstname.lastname@example.org 1 Case Information2 Contact Information3 Products4 Review & Submit General case: It may take several days or more to gather all the information you need so plan ahead to have a comfortable implementation. If you hire us to construct your company database, know that it usually takes up to 10 business days to build and deploy a working solution, depending on the timing and quality of information you send us. Case InformationCompany name*Website URLNumber of lives*Additional InformationAdditional informationDo not include any protected health information. Save progress and continue later Case Implementation Contact InformationName* First Last Email* Phone*Extension Save progress and continue later Select ProductsAdd one product per line. Click the plus button to add additional products.Pre-built, collaborating carrier products enroll for free. Check product availability. Benefit administration for $0 PEPM is available when select products are enrolled. Common Census can also build other benefits. Learn about custom buildsCarrier nameProduct nameImport coverageExport type Carrier Rep Contact Information Add carrier rep contact information Carrier nameRep nameEmailPhone Additional ExportsPayroll ExportNoneExcelOtherPayroll vendor nameCOBRA ExportNoneExcelEDICOBRA vendor nameACA ExportNoneExcelEDIACA vendor name Save progress and continue later Ready to submit If you are ready to submit the case summary form, please go ahead an do so. Submit later If you would like more time, you may click the Save and continue later link below. This will provide you with a link where you can access the working form for up to 30 days. Once you submit the form, you must contact BenefitsUSA sales directly to make any changes to the case summary. Email: Phone: (207) 854-5454 x203 Note: this is not a valid agreement until reviewed and approved by BenefitsUSA. Save progress and continue later BenefitsUSA Sales National Sales Manager office (207) 865-6565 #3 email@example.com Implementation process InformationSubmitting this case summary.SetupA Benefits USA team member will discuss having our team assist you.Upload InformationWe will provide you with a secure login.Complete ConfigurationBenefitsUSA will build and release the case.