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Group Information
Account Name
*
Services Requested
*
Invoice Reconciliation Audits
Bill Consolidation
Subconsolidation
Payroll Reconciliation
Payments
Other
Carrier Bill Retrieval
Plan Year Begin Date
*
Month
/
Day
/
Year
Preferred Implementation Timing
*
Within the next:
1 - 3 Months
3 - 6 Months
9+ Months
Number of Eligible Employees
*
Enrollment Platform(s)
*
Number of Carriers
*
Estimated Number of Carriers with List-Bill
*
Payroll Platform
Pay Frequency
Please Select
Weekly (52 periods)
Weekly (48 periods)
Bi-Weekly (26 periods)
Semi-Monthly (24 periods)
Monthly (12 periods)
Your Information
Company name
*
I am a:
*
Agent
Broker or Consultant
PEO
Other
First Name
*
Last Name
*
Email
*
Mobile Phone Number
Additional information you'd like to share
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