CBA Intake Form
Take back control of your healthcare spending.

The key to getting you a fast and accurate quote with the best pricing available is for you to collect and submit all your employees census information along with your 9-Digit FEIN/Tax ID.

Need help? Contact us at CBA@decisely.com or 704-218-2899.

"*" indicates required fields

Step 1 of 6

16%

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Lead Record Type

Business Information

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Salesforce ID

Name*

First Last

Email Address*

Phone*

Legal Name of Operation*

Business Street Address*

Business Address 2 (optional)

City*

State*

Select a state...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

5-Digit Zip Code*

Employer ID Number (FEIN)*

Short Code*

Number of full-time employees*

Please enter a number less than or equal to 9999.

Number of part-time employees

Please enter a number less than or equal to 9999.

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Station Information

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Check here if station address is the same as the business address

Station Street Address*

Station Address 2 (optional)

Station City*

Station State*

Select a state...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Station 5-Digit Zip Code*

Are you a New or Existing DSP?*

New

Existing

When did you start operation for Amazon?*

MM slash DD slash YYYY

When do you intend to start operations for Amazon?*

MM slash DD slash YYYY

Are you currently under contract with Amazon?*

Yes

No

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Additional Information

What is your desired start date for benefits?

January 1stFebruary 1stMarch 1stApril 1stMay 1stJune 1stJuly 1stAugust 1stSeptember 1stOctober 1stNovember 1stDecember 1st

Do you currently offer health insurance coverage?*

Yes

No

Who is your current medical carrier?*

United Healthcare (UHC)AnthemBlue Cross or Blue ShieldAetnaCignaHumanaKaiserOther (please specify)

Other Medical Carrier? Please specify:*

Approximately how many employees are enrolled?*

What is your coverage renewal month?*

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Who is your current payroll provider?*

Select one of the followingADPPaycomNo Payroll Provider / N/AOther

Other provider? Please specify:*

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Current Plan Designs and Rates for Medical

The more information we are able to provide the carriers, the more likely our ability to source affordable coverage.

Need help? Contact us at CBA@decisely.com or 704-218-2899.

Upload Your Relevant Documents Here

Drop files here or Select files

Max. file size: 100 MB.

Information Needed:

• Current plan designs and rates for medical – available from plan documents and bills
  • Previous 2 years plan designs and renewals
  • Contribution strategies
  • Renewal dates
  • Claims reports
  • Stop-loss contract (if your plan is self-funded)
  • Any outstanding high-claims issues
  • Current PPO and Rx networks
  • HSA product used (if HSA is offered)

Please note: Your insurer may not provide you with all the above information; for example, if your business is on a fully-insured plan, you won’t have access to claims reports. That’s okay! Provide the data you have.

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Employee Census Information

Please upload an employee census, available from payroll reports and insurance plan reports, that includes the following information:

• Primary and dependent names
• Dates of birth, genders
• Zip codes
• Employee W-2 and 1099, classes and salary designations

No available employee and dependent census data? Click ‘Download Spreadsheet’ to use our employer information form (census form).

Need help? Contact us at CBA@decisely.com or 704-218-2899.

Download Spreadsheet

Employee Census Information

Max. file size: 100 MB.

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Quoting Information

Please check all that apply for quoting:

Medical

Dental

Vision

Basic Term Life

Voluntary Term Life

Critical Illness

Accident

Short Term Disability

Long Term Disability

Additional Comments:

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Lead Source Detail

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Expected Opportunity Type

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Lead Source

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Lifecycle Status

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Channel

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Type of Referral

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utm_source

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utm_medium

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utm_campaign

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utm_term

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Report

Report 1

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Report

Report 2

Email

This field is for validation purposes and should be left unchanged.

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