MaxBen New Group Notification MaxBen New Group Notification MaxBen New Group Notice "*" indicates required fields Group Information Group Name*Policy Number*Effective Date* MM slash DD slash YYYY Number of Lives*Locations*Select all that apply. Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Organization's Main Contact* First Last Email* Phone* Plan Information Advisor* First Last Email* Phone*MaxBen Plan & Rate* Max MM – Premium Max DB – Premium (EAP only) Max DB – Premium Bundled (EAP & BAS) Max DB – ASO/FFS (Standard) Rate (pepm)*Intervention Rate ($/hr)*Admin Rate (pepm)*Group Renewal Month*Select…JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberForm Submitted by* First Last Email*
