7223 West 95th Street Suite 301
Overland Park, Kansas 66212-2291
1-800-382-4121
https://www.ataamerica.com/

Request for Electronic Enrollment

Complete the following information to allow electronic enrollment form collection for each new group

Your Information

Please fill out the following information in order to receive status notifications about the group's electronic enrollment.

General Agent's Name:

Full name is required.

General Agency's Name:

Agency Name is required.

Your Email:

Your email required.

Your Phone:

Your phone is required.

How often do you want to receive status updates regarding this group?

Group Information

Please fill out the following information about the group. The estimated number of employees will be used to estimate when a requested quote is eligible for the prescreen process.

Group Name:

Group name is required.

Street Address:

Please provide a street address.

City:

Please provide a city.

State:

Please provide a state.

Zip:

Please provide a valid zip code.

Nature of Business:

Nature of business is required.

SIC (optional):

Estimated # of Full-Time Eligible Employee:

Required field.

Group Contact Person

Please provide contact information for the group's contact person if you want the group to also be notified and receive status update emails.

Upon submission of this form, the contact person listed will receive an email with a hyperlink and instructions.

Contact's Name:

Group contact's name is required.

Contact's Email:

Group contact's email required.

Check here to add additional contact email addresses.

Add as many contact email addresses as you wish. Use the (+) button to list all contact email addresses.

Additional Contact Name & Email Addresses

Manual Quotes or SBC

If you have already run the manual quotes for this group, please upload them here. If you do not have a manual quote for this group, please provide a census and a Summary of Benefits and Coverage (SBC). If you do not have a Summary of Benefits and Coverage, please use the space provided below to indicate which plans of benefits you would like quoted. Furthermore, please attach any extra documentation you feel is necessary.

Select file... Please upload a PDF file.

Explanation of Benefits Requested (optional)