Employer Enrollment Form

INSTRUCTION: THIS FORM IS TO BE COMPLETED BY THE EMPLOYEER GROUP

Employer Information

Employer Name: Effective Date Tax/EIN

of Coverage:
John Dentist, DDS 07/01/2017
Primary Industry DBA (Yes/No) Staffing Agency (Yes/No)
Dentistry No No
Location Address Mailing Address
123 Apple Street, San Antonio, Texas 78216 123 Apple Street, San Antonio, Texas 78216
Phone Number Fax Number Website

210-872-8746 210-849-2832 N/A

Our established Trial Period is the First of Trial Period Used For Example: Effective On
the month following 30 days. If you would N/A Hired On N/A
like a different one, outline it here N/A

Owner & Trustees Information

Owner Last name Owner First Name Owner Title
Dentist John DDS
VEBA Trustee Last Name VEBA Trustee First Name VEBA Trustee Title
Dentist John DDS
VEBA Trustee Last Name VEBA Trustee First Name VEBA Trustee Title

VEBA Trustee Last Name VEBA Trustee First Name VEBA Trustee Title

Contact Person who will email missing paperwork and employee

information if needed
First Name Last Name Email
Mitchell Bigley Mitchell.bigley@excelbenefits.biz

Position Phone Fax

Operations Manager 2105931500 Ext. 103 2105930087
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Employer Enrollment Form

INSTRUCTION: THIS FORM IS TO BE COMPLETED BY THE EMPLOYEER GROUP

Billing Information Person who will receive emailed copies of monthly invoice
Billing Contact: Email Address
Janette Rojas janette@corpsolpeo.com
Position Phone Fax
Accounting Representative 8887854018 9568001251

Broker Information (If Applicable) Brokers must be approved & contracted by

Managing General Agent (MGA)

First Name Last Name Email

Michael Bigley Mike.bigley@excelbenefits.biz
Position Phone Fax
President 2105931500 Ext. 104 2105930087

Does this person work at an agency (YES/NO): Yes

Name of Agency if YES: Excel Benefits, Inc.

Plan Options

ZERO $500 $1000 $1500

$2000

$3000 $3500 $3500 HSA $5000 $6350

Commercial Group Intermediaries
16 Executive Court Suite 4
South Barrington, IL 60010 (847)
713-4700

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