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Contract Benefit Specialist Application
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Contract Benefit Specialist Application
Contract Benefit Specialist Application
admin
2018-03-20T18:41:41+00:00
Contractor Information
First Name
*
Last Name
*
Date of Birth: MM/DD
*
Last Four Digits of Social Security Number
*
Preferred Phone
*
Primary Email
*
Street Address
*
Apt, Suite, Bldg. (optional)
City
*
State / Province / Region
*
Postal / Zip Code
*
Country
*
Experience
Years of Enrollment Experience
*
What are your speciality areas?
One-on-one Enrollment
Case Manager
Call Center
Team Leader
If case management is a specialty area, list the enrollment group(s) below. If not, enter "NA."
*
If team leadership is a specialty area, list the enrollment group(s) below. If not, enter "NA."
*
Do you hold a High School Diploma or higher?
*
Yes
No
GED
Types of license:
Life
P&C
Accident & Health
List special benefit or CE education courses. If none, please enter "NA."
*
Do you currently hold an Errors & Omissions Insurance Policy?
*
Yes
No
If yes, list the Carrier, Policy Number, and Expiration Date.
If no, are you willing to provide your own policy?
Yes
No
Do you have a valid Driver's License?
*
Yes
No
Are you proficient with enrollment software?
*
Yes
No
If yes, list enrollment platforms in which you have experience:
What is the largest group size you have enrolled in the past five (5) years?
*
Are you bilingual?
*
Yes
No
If yes, which language(s) do you speak fluently?
Do you have auto insurance?
*
Yes
No
List your auto insurance carrier:
Do you have core benefit experience?
*
Yes
No
Do you have voluntary benefits experience?
*
Yes
No
Select all products enrolled within the past five (5) years:
HSA
Vision
Term Life
Short-term Disability
High deductible plans
Wellness
Employee Assistance
Medical
Pet Insurance
Hearing
Universal Life
Long-term Disability
Long-term Care
Cancer Insurance
Legal
Dental
Whole Life
Basic Life/AD&D
Flex Spending Account
Critical Illness
Accident Insurance
Teledoc
Select all that apply within your last five (5) years of experience.
Call Center
Utilized Voice Authorization
Mock Presentation
Laptop Presentation
Benefit Fairs
4th Quarter Enrollments
One-on-one Presentation
Group Enrollments
Group Presentation
Daily Quality Measurements
Are you comfortable explaining benefits to a large group?
*
Yes
No
Non-residence license(s) held as of the date of this application:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
Are you willing to obtain any non-residence state licenses?
*
Yes
No
Will you need to use a Clear Track HR laptop for this enrollment?
*
Yes
No
Do you have a laptop or desktop computer with high-speed internet access?
*
Yes
No
If yes, which operating system do you use?
Windows
MAC
Linux
Other
Emergency Contacts
Primary Contact
Full Name of Primary Contact
*
Relationship
*
Phone
*
Address
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
Secondary Contact
Full Name of Secondary Contact
*
Relationship
*
Phone
*
Address
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
Travel Information
If you have travel restrictions or limitations, please explain. If no, please enter "NA."
*
Do you have a major credit card?
*
Yes
No
Do you have a bank account for use with direct deposit?
*
Yes
No
Airport Nearest Your Home
*
Enter your preferred airline.
If applicable, enter your Frequent Flyer Miles Number.
If applicable, enter your AAA Member Number.
*
Enter your preferred rental car company.
If applicable, enter your rental car membership number:
Are you a tobacco user?
Yes
No
References
Full name of referrer:
Phone
Referrer title/occupation
Full name of referrer:
Phone
Referrer title/occupation
Full name of referrer:
Phone
Referrer title/occupation
Additional Comments
In the space below, provide any additional information you believe to be important as we consider your application.
Certification
My responses are true and complete.
*
I hereby certify that all listed answers and responses are true and complete to the best of my knowledge.
If contracted, I understand that false information could lead to my dismissal.
*
If this application leads to employment, I understand that false or misleading information in this application or in my interview may result in my termination from the company.
Verification
Please enter any two digits
*
Example: 12
This box is for spam protection - <strong>please leave it blank</strong>: