SmartConnect Onboarding Profile * Required "*" indicates required fields Step 1 of 4 25% Who are you?I am a newly contracted partnerI am a consultant onboarding a member in the CaptiveConsultant ContactName* First Last Email* Phone* Brokerage Name* Client InformationWhat is the name of your organization?* What is your company's billing address?* Where is the company's physical headquarters?* What is the total employee population headcount?*What is the total employee population headcount over the age of 64?* Will you be sharing census data with SmartConnect?* Yes No Company LogoMax. file size: 50 MB.All logos must be a png file that has a transparent background.Do we have permission to use your company logo in our promotional materials?*YesNo Primary HR Contact Information*Additional contacts can be added in comments section belowName* Email* Phone* Primary HR Contact Information*Upon completion of this form a Welcome Email will be sent to contact providedName* Email* Phone* Primary Contact for Billing/Invoice DeliveryName* Email* Phone* Invoice Frequency*QuarterlyAnnuallySmartConnect Platform Subscription*Active + (Sharing Census Data)Active Member Benefit & Enrollment InformationPlease confirm the group's open enrollment period? (if applicable) Please upload the employee benefits guide and monthly contributions: PDF OnlyIf the file size is to large to upload, please email to partner.connect@smartmatch.comMax. file size: 50 MB.If the file size is to large to upload, please email to partner.connect@smartmatch.comWhen the Medicare eligible employees opt out of the group benefits while still actively employed, what group benefits can they keep, if any? Comments {Additional Internal Contacts}CommentsWho completed this form?Name* Email* Phone* Terms & Conditions Disclaimer* By submitting this form, I agree that I have returned the signed Service Application to SmartConnectPhoneThis field is for validation purposes and should be left unchanged.
