BeniComp Select List of Participants

ALMOST THERE!

Thank you for submitting your application to BeniComp Select.

Please complete the below form so we can process your application.

This is a list of the participants joining the plan, we need their BeniComp Select Class and an unique email address for each participant.

If you have an Excel or Word doc you can choose to upload the list below.

Company *
Contact Name Contact Name * First Last
Contact Email

Please note - If you are both a group contact and participant, we require a different email for your participant information.
Select the number of BeniComp Select participants

If there are more than 15 BeniComp Select participants, please upload a list in an excel document using the "Choose File" button below.
Opt in to free Unlimited Telemedicine: *

Opt in to free Unlimited Telemedicine: Yes No

This is an included feature of the policy. Your participants would have 24/7 access to free, unlimited virtual doctors visits if you opt in.

Please note, your base health plan may already include this service.
Would you like to offer unlimited online Mental Health Therapy for an additional $100 per participant? *

Would you like to offer unlimited online Mental Health Therapy for an additional $100 per participant? Yes No
Upload a list of BeniComp Select participants or use the form below

Attach Files

You can upload a list of BeniComp Select participants using the "Choose File" button. Please include name, email address, and BeniComp Select class for each participant.
Participant 1 Name Participant 1 Name First Last
Participant 1 Email

Participant emails cannot be duplicated. If you are both the group contact and a participant please provide a unique email address.
Participant 1 Class

Please provide the BeniComp Select Class the participant belongs to. For example, if your BeniComp Select policy has 2 classes, Owners and Managers, and Participant 1 is an Owner, you would write "Owner" under Participant 1 Class.
Participant 2 Name Participant 2 Name First Last
Participant 2 Email

All participant emails must be unique.
Participant 2 Class

Please provide the BeniComp Select Class the participant belongs to. For example, if your BeniComp Select policy has 2 classes, Owners and Managers, and Participant 2 is a Manager, you would write "Manager" under Participant 2 Class.
Participant 3 Name Participant 3 Name First Last
Participant 3 Email

All participant emails must be unique.
Participant 3 Class
Participant 4 Name Participant 4 Name First Last
Participant 4 Email

All participant emails must be unique.
Participant 4 Class
Participant 5 Name Participant 5 Name First Last
Participant 5 Email

All participant emails must be unique.
Participant 5 Class
Participant 6 Name Participant 6 Name First Last
Participant 6 Email

All participant emails must be unique.
Participant 6 Class
Participant 7 Name Participant 7 Name First Last
Participant 7 Email

All participant emails must be unique.
Participant 7 Class
Participant 8 Name Participant 8 Name First Last
Participant 8 Email

All participant emails must be unique.
Participant 8 Class
Participant 9 Name Participant 9 Name First Last
Participant 9 Email

All participant emails must be unique.
Participant 9 Class
Participant 10 Name Participant 10 Name First Last
Participant 10 Email

All participant emails must be unique.
Participant 10 Class
Participant 11 Name Participant 11 Name First Last
Participant 11 Email

All participant emails must be unique.
Participant 11 Class
Participant 12 Name Participant 12 Name First Last
Participant 12 Email

All participant emails must be unique.
Participant 12 Class
Participant 13 Name Participant 13 Name First Last
Participant 13 Email

All participant emails must be unique.
Participant 13 Class
Participant 14 Name Participant 14 Name First Last
Participant 14 Email

All participant emails must be unique.
Participant 14 Class
Participant 15 Name Participant 15 Name First Last
Participant 15 Email

All participant emails must be unique.
Participant 15 Class
List of Participants
Joe Smith, joesmith@benicomp.com, Manager Jane Smith, janesmith@benicomp.com, Owner
Use the following format to send a list of participants joining the plan. Please include name, email and BeniComp Select class for each participant.
Will you be offering MeMD (unlimited telemedicine) as an ancillary service to your BeniComp Select policyholders?

Will you be offering MeMD (unlimited telemedicine) as an ancillary service to your BeniComp Select policyholders? Yes No

Unlimited telemedicine is available as an ancillary service for all BeniComp Select policyholders. Unlimited telemedicine costs $100 per participant per year.