Benfits Data Input

Choose your name from this drop down box.*

Your Name*

Your Email*

For what division is this account data?*

Trustpoint Benefits

Beneficial Associates Inc

What Type of data are we adding?*

New Business

Renewal Business

Account/Policy Changes

Account/Policy Cancelation

For how many policies are you adding data?*

Please enter a number from 1 to 10.

For example if there are two (2) group health, one (1) dental and one (1) vision, then enter four(4) policies.

New Business Account Information

Enter Legal Name of Account*

Enter DBA Name (blank if N/A)

Contact Name*

Prefix First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Enter Name of Producer/Account Executive*

Enter Name of Account Manager/Representative*

Enter Standard Industry Code for this Account (SIC)*

Enter Number of Eligible Employees*

Is this an existing account?*

If we already have an account set up for Trustpoint P&C, Trustpoint Benefits or Beneficial Associaties Inc then select YES.

Yes

No

Renewal / Change / Cancellation Account Information

Enter Name of Account*

Has the number of eligible employees changed?*

Yes

No

Enter Updated Number of Eligible Employees

Information for 1st Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 2nd Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 3rd Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 4th Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 5th Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 6th Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 7th Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 8th Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 9th Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Information for 10th Policy

Is this a rewrite?*

Yes

No

If this is a new company or policy replacing an existing policy choose YES.

Enter the expiring policy number.*

Choose the line of business for this policy.*

Policy Number*

Enter the Effective Date of This Policy*

Enter the Expiration Date of This Policy*

Enter the Cancelation Date of This Policy*

Enter the Reason for Cancelation*

Select the Parent:Writing Company Combination for This Policy*

Specify Parent and Writing Company Combination for This Policy*

Enter Negotiated Commission Percentage*

You may need to back into this by dividing the estimated revenue by the estimated premium.

Enter the Annual Estimated Premium for This Policy*

Enter the Annual Estimated Revenue for This Policy*

Enter the name of the Account Manager/Representative for This Policy*

Enter the name of the Producer/Executive for This Policy*

Note: for BAI new business the primary producer should be the Trustpoint producer entered at zero percent (0%) commission.

Enter Producer Commission*

Enter the name of the 2nd Producer/Executive for This Policy

Note: for BAI new business the 2nd producer should be the BAI producer entered at their appropriate percentage.

Enter 2nd Producer Commission

Enter the name of the 3rd Producer/Executive for This Policy

Enter 3rd Producer Commission

Enter the name of the Broker for This Policy

Enter Broker Commission

Describe required changes below.*

For Trustpoint and BAI Policies

New Business Account Information

Renewal / Change / Cancellation Account Information

Information for 1st Policy

Information for 2nd Policy

Information for 3rd Policy

Information for 4th Policy

Information for 5th Policy

Information for 6th Policy

Information for 7th Policy

Information for 8th Policy

Information for 9th Policy

Information for 10th Policy