General case: Allow 1 week of lead time for you to gather all required case information before case building starts. It takes 10 Business days to build and deploy after Common Census has received all carrier, product, and census information.

• Case Information

• Case name*
• Website URL
• Enrollment start date*
  Date Format: MM slash DD slash YYYY
• Enrollment end date*
  Date Format: MM slash DD slash YYYY
• Number of lives*
• Service type*
  Select all that apply
  • Open enrollment
  • New hire enrollment
  • Benefits administration
• Enrollment methods*
  Select all that apply
  • Online (self-service)
  • Online (enroller assisted)
  • Call center
• Defined Contribution
  • Yes
  • No
• Specify the parameters for defined contribution (examples: by location, division, class, years of service; based on a percentage of salary or a fixed dollar amount). The more complete the explanation, the better.

• Additional Information

• Additional information
  Do not include any protected health information.

• Producer Primary Contact Information

• Agency/Company name*
• Name*
  First Last
• Email*
  Enter Email Confirm Email
• Phone*
• Extension

• Case Implementation Contact Information

• • Use producer contact information
• Name*
  First Last
• Email*
  Enter Email Confirm Email
• Phone*
• Extension

• Select Products

• Add 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 builds

  Carrier name	Product name	Import coverage	Export type

• Carrier Rep Contact Information
  • Add carrier rep contact information

• Carrier name	Rep name	Email	Phone

• Additional Exports

• Payroll Export
  NoneExcelEDI
• Payroll vendor name
• COBRA Export
  NoneExcelEDI
• COBRA vendor name
• ACA Export
  NoneExcelEDI
• ACA vendor name

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 Common Census sales directly to make any changes to the case summary.

Email: ccsales@commoncensus.com
Phone: (207) 854-5454 x214

Note: this is not a valid agreement until reviewed and approved by Common Census.