Prospect Form - Certifi

Main Contact Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Who will Certifi be billing?(Required)

Individual

Group

Individual and Group

Who will Certifi be remitting to?(Required)

Client

Carrier

Third Party

Sponsor Group

Sponsor

Benefit Types to Be Billed(Required)

Number of Lives in Billing System(Required)

Number of Groups(Required)

Average Group Size(Required)

Number of Individual Enrollments(Required)

Is benefits billing/accounting outsourced today?(Required)

Yes

No

Names of Current Billing Partners/Providers(Required)

Upstream HR Enrollment System(s) Name (If more than one, please describe the population managed on each system)(Required)

Comments

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