For enrollments, please complete the required information below:
 

Group Name:
Approved Coverage:
Effective Date:

 

Contact Name for Group:
Email:
Phone Number:

 

Agent Name:
Email:
Phone Number:

 

Agents Assistant Name (if you are working with one):
Email:
Phone Number:

 

The approved group quote MUST be attached. Include a group census and ACH form.

 

Please email information to Agent Support, agentsupport@directbenefits.com.