New Client Intake Form

What is the consultant/broker's name? *
What is the consultant/broker's name?
First and last name please.
Launch Date *
Launch Date
The start date employees will be able to use Nice.
Please provide a number even if it's an estimate.
Checkbox *
Please include individual/family
Currently $25 PEPM in MN and $30 PEPM in additional states. Enter zero if this is virtual only.
$
Currently $6 PEPM. Enter zero if this is a full service contract.
$
Enter zero if there is no commission being charged.
$
Typically only groups with an HSA in place have a visit fee. Enter zero if there is no fee.
$
What is the full name of the contact at the client? *
What is the full name of the contact at the client?
This call typically lasts < 30 mins.
What is the name of the account executive for this account?
What is the name of the account executive for this account?
Leave blank if there is none.