This document is a business engagement agreement from enhancedcareMD that collects company and employee benefit information. It requests the company name, address, number of full-time and part-time employees, details on current health benefits including plan type, deductible, renewal date, enrollment numbers, and premium contributions. It also collects the agent's contact information and asks the company to submit the form to enhancedcareMD's sales email for further discussion on improving their employee benefits strategy.

1. Email: sales@enhancedcaremd.com Send forms to enhancedcareMD
Fax: (585) 419-2061
Phone: (585) 419-7900
Hours: M-F 9am-5pm EST
BUSINESS ENGAGEMENT AGREEMENT
Thank you for your interest in enhancedcareMD’s Smarter Choices. The information below will help set the agenda for
our discussion going forward, but before we begin, do you have any concerns you would like addressed at this or follow-
up meetings?
COMPANY CONTACT INFORMATION
Name:
Email:
EIN: Phone:
Address: City:
State: Zip:
We will work with your HR staff to complete a full census in our next step, and that will allow us to make recommendations
to move forward with. For the purposes of this conversation, the 50,000ft view of your company statistics will help us
match a strategy to the scope of your needs.
EMPLOYEE STATISTICS
Total # of employees: Full-time employees (>30 Hrs.): Part-time employees (<30 Hrs.):
INFORMATION ON CURRENT HEALTH BENEFITS
If your current benefits include group health insurance fill out the following information:
Type of plan(s) offered? PPO, HDHP? :
Deductible amount:
What is the renewal date?
# of employees currentlyenrolled :
Premium contribution-employer:$
Premium contribution-employee:$
What is your Benefits strategy? (Cost, Options,Retention)
Additional details you wish to share:
CurrentBroker name:
Phone & Email:
AGENT INFORMATION
Name: Email:
Agent ID: Phone:
PLEASE SUBMIT FORM TO SALES@ENHANCEDCAREMD.COM