First Name *

Last Name *

Email *

Phone *

Company *

Address *

City *

State *

Postal code *

Tax ID

Type of Entity

Number of Eligible Employees

Primary Contact Title *

Primary Contact Name *

Primary Contact Phone Number *

Primary Contact Email *

Secondary Contact Title *

Secondary Contact Name *

Secondary Contact Email *

Secondary Contact Phone Number *

Invoicing Contact Title *

Invoicing Contact Name *

Invoicing Contact Phone Number *

Invoicing Contact Email *

Broker Agency Name *

Broker Name *

Broker Email *

Broker Phone Number *

Benefit Plans Start Date *

Benefit Plans End Date *

Open Enrollment Start Date

Open Enrollment End Date

How do COBRA participants elect benefits during open enrollment? *

How many benefit eligible employees do you have? *

Upload Summary Benefits Description or Open Enrollment Booklet to be provided to COBRA participants. *

Upload Participant Booklet

Max Children Charged

The number of children that can be counted towards the cost for Member-Level rates

Max Child Age for Children Charged

(The max age of a child to be considered to the Max Children Charged(The max age of a child to be considered to the Max Children Charged determination.) determination.)

*Proceed to next step if member level rate option not applicable*

Upload File here

NUESYNERGY WORLD HEADQUARTERS

4601 College Blvd (Suite 280)

Leawood, KS 66211

SALES INQUIRIES

1-855-890-7239 (option 4)

Sales@NueSynergy.com

CUSTOMER SERVICE

1-855-890-7239 (option 2)

CustomerService@NueSynergy.com

COBRA SUPPORT (BROKER/EMPLOYER)

1-855-890-7239 (option 4)

COBRA@NueSynergy.com

EMPLOYER SUPPORT

1-855-890-7239 (option 3)

EmployerSupport@NueSynergy.com