VIDEO CREATION REQUEST FORM
+ GAP
IMPORTANT! Read First:
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CLIENT NAME
*
CLIENT Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
AGENCY NAME
*
AGENT NAME
*
First Name
Last Name
CHELTEN BENEFITS GROUP AGENT
*
First Name
Last Name
Agent Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Due Date
*
-
Month
-
Day
Year
Date
Push-to-Play Employee Meeting Video?
*
YES
NO
Paycheck Works Video?
*
YES
NO
AHW Video?
*
YES
NO
PLEASE PROVIDE US WITH A "BENEFITS AT A GLANCE" (BAAG) FOR EACH BENEFIT OFFERED.
GAP INSURANCE CARRIER
*
SL&A
Monitor Life
AmFirst
PreMed Defender
OptiMed
Other
HEALTH PLAN BASE
+ GAP
HEALTH PLAN CARRIER
*
(Ex. HAP)
*
POS
HMO
PPO
Other
GAP CARRIER
*
(Ex. AmFirst)
COMBINED DEDUCTIBLE
*
(Ex. $500 Deductible)
COMBINED COINSURANCE
*
(Ex. 20% to Max, $1,000 Coinsurance)
TOTAL DEDUCTIBLE & COINSURANCE
*
(Ex. $1,500)
ADDITIONAL COMMENTS
HEALTH PLAN BUY UP 1
+ GAP
HEALTH PLAN CARRIER
(Ex. HAP)
POS
HMO
PPO
Other
GAP CARRIER
(Ex. AmFirst)
COMBINED DEDUCTIBLE
(Ex. $500 Deductible)
COMBINED COINSURANCE
(Ex. 20% to Max, $1,000 Coinsurance)
TOTAL DEDUCTIBLE & COINSURANCE
(Ex. $1,500)
ADDITIONAL COMMENTS
HEALTH PLAN BUY UP 2
+ GAP
HEALTH PLAN CARRIER
(Ex. United Health Care)
POS
HMO
PPO
N/A
Other
GAP CARRIER
(Ex. AmFirst)
COMBINED DEDUCTIBLE
(Ex. $500 Deductible)
COMBINED COINSURANCE
(Ex. 20% to Max, $1,000 Coinsurance)
TOTAL DEDUCTIBLE & COINSURANCE
(Ex. $1,500)
ADDITIONAL COMMENTS
PRESCRIPTIONS, DOCTOR OFFICE, URGENT CARE & EMERGENCY ROOM
PRESCRIPTIONS
TIER 1:
*
(Ex. $20 Copay)
TIER 2:
(Ex. $40 Copay)
TIER 3:
(Ex. $75 Copay)
TIER 4:
(Ex. $100 Copay)
TIER 5:
(Ex. 50% to $250)
TIER 6:
(Ex. 50% to $500)
ADDITIONAL COMMENTS
DOCTOR OFFICE VISIT
PRIMARY
*
(Ex. $40 Copay)
SPECIALIST
(Ex. $60 Copay)
ADDITIONAL COMMENTS
EMERGENCY ROOM VISIT
EMERGENCY ROOM VISIT
*
(Ex. $250 Copay)
ADDITIONAL COMMENTS
URGENT CARE VISIT
URGENT CARE VISIT
*
(Ex. $75 Copay)
ADDITIONAL COMMENTS
CHIROPRACTIC, LIFE INSURANCE, DENTAL & VISION
CHIROPRACTIC CARE
CHIROPRACTIC
(Ex. $30 Copay)
ADDITIONAL COMMENTS
LIFE INSURANCE
LIFE INSURANCE
(Ex. FLAT $20,000)
CARRIER NAME
(Ex. UNUM)
VOLUNTARY
YES
NO
N/A
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
ADDITIONAL COMMENTS
DENTAL
CARRIER
VOLUNTARY
YES
NO
N/A
PREVENTIVE
(Ex. Preventive: 100%)
BASIC
(Ex. Basic: 80%)
MAJOR
(Ex. Major: 50%)
ORTHO
(Ex. Ortho: 50% or None)
DEDUCTIBLE
(Ex. Deductible: $50/$150 or None)
APPLIES TO PREVENTIVE
(Ex. Yes or No)
ANNUAL MAX
(Ex. Annual Max: $1,000)
ORTHO LIFETIME MAX
(Ex. $1,000 or N/A)
ADDITIONAL COMMENTS
VISION
CARRIER
VOLUNTARY
YES
NO
N/A
EXAM
(Ex. EXAM: $10 Copay, every 12 Months)
FRAMES
(Ex. FRAMES: $10 Copay, every 12 Months)
PRESCRIPTION GLASSES
(Ex. $25 Copay, 24 Months)
CONTACTS
(Ex. Up to $120, every 24 months)
ADDITIONAL COMMENTS
SHORT TERM DISABILITY, LONG TERM DISABILITY & CRITICAL ILLNESS
SHORT TERM DISABILITY
CARRIER
VOLUNTARY
YES
NO
N/A
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
WAITING PERIOD ACCIDENT
(Ex. 7 Days)
WAITING PERIOD ILLNESS
(Ex. 7 Days)
BENEFIT DURATION
(Ex. 26 Weeks)
WEEKLY BENEFITS
(Ex. 60% up to $750)
ADDITIONAL COMMENTS
LONG TERM DISABILITY
CARRIER
VOLUNTARY
YES
NO
N/A
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
WAITING PERIOD
(Ex. 180 Days)
BENEFIT DURATION
(Ex. Benefit Duration to Age 65)
MONTHLY BENEFITS
(Ex. 60% up to $3,000)
ADDITIONAL COMMENTS
VOLUNTARY LIFE INSURANCE
CARRIER
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
COVERAGE INCLUDES
LUMP SUM DISABILITY
CARRIER
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
COVERAGE INCLUDES
IDENTITY THEFT
CARRIER
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
COVERAGE INCLUDES
CRITICAL ILLNESS
CARRIER
VOLUNTARY
YES
NO
N/A
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
COVERAGE INCLUDES
ADDITIONAL COMMENTS
ACCIDENTAL INJURY COVERAGE
CARRIER
VOLUNTARY
YES
NO
N/A
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
COVERAGE INCLUDES
ADDITIONAL COMMENTS
HOSPITAL COVERAGE
CARRIER
VOLUNTARY
YES
NO
N/A
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
COVERAGE INCLUDES
ADDITIONAL COMMENTS
CANCER COVERAGE
CARRIER
VOLUNTARY
YES
NO
N/A
OPTIONAL COVERAGE AVAILABLE
YES
NO
N/A
COVERAGE INCLUDES
ADDITIONAL COMMENTS
VOLUNTARY COVERAGE
COVERAGE INCLUDES
ADDITIONAL COMMENTS
SUBMIT
ALL FIELDS HAVE BEEN COMPLETED AND ARE READY FOR VIDEO CHANNEL SUBMISSION
*
Yes
Submit
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