Welcome Business Owner

Complete Your Intake Form

PLEASE READ BEFORE PROCEEDING!

1-2 Staff Members or Couples without additional staff: Click here to get started.

2-49 Staff Members: This form only supports manual entry for up to ten staff members. If you have more than ten members, and you already have a completed staff census, you can upload it on the following page. If not, you can continue with this intake and provide it later.

A staff census needs to include all eligible employees even if they're not requesting coverage. Please also be sure your staff census includes all of the following for each staff member. You can send your completed census to us in xls or pdf format. Or you can come back here and upload it to your intake form.

For Each Employee, We Need..

Employee Full Name
Employee Job Title
Employee Hire Date
Average Hours Worked Weekly
Date of Birth
Gender
Residential Zip Code
Full Names, Dates of Birth and Genders for all Spouses and Dependents

Company Profile

Company Name

Main Contact First Name

Main Contact Last Name

Main Contact Title

Main Contact Phone *

Main Contact Email *

Company Website

Headquarters Address

City

State

Zip Code

County

Mailing Address If Different

How is your company structured?

Staff Member One Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
Does This Staff Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member One Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member One

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Two Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
Does This Staff Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Two Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Two

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Three Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
Does This Staff Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Three Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Three

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Four Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
Does This Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Four Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Four

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Five Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
Does This Staff Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Five Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Five

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Six Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
Does This Staff Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Six Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Six

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Seven Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
Does This Staff Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Seven Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Seven

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Eight Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Eight Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Eight

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Nine Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Average Hours Weekly
Does This Staff Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Nine Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Nine

Add Another Staff Member? *

Yes

No, I'm All Done Adding Staff

Staff Member Ten Profile

Full Name
Job Title
Date of Birth
Gender
Hire Date
Does This Staff Member Have Any Ownership
If Married Spouse's Full Name
If Married Spouse's Date of Birth
If Married Spouse's Gender

Staff Member Ten Dependents: Tell Us Their Full Name, DOB & Gender (one dependent per line)

Additional Comments About Staff Member Ten

Contact Us

Mon-Fri : 9:00 - 6:00 PM

Sat: 9:00 AM - 1:00 PM

[email protected]

866-758-7229

520-272-5950

7150 E Camelback Rd Ste 310, Scottsdale AZ 85251

Get Started Now

THE LEGAL STUFF

To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1- 877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

* Medicare Advantage, Medicare Supplemental Insurance, and Part D options can be explored.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov. , 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options. Attention: This website is operated by Cornett Consulting Insurance Agency, Inc. and is not the Health Insurance Marketplace® website.

Cornett Consulting Insurance Agency. is licensed in AZ, FL, TX & VA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

Cornett Consulting Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call your plan’s customer service phone number for more information about your specific benefits, limitations, exclusions and costs.

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