nippon life benefits

Enrollment Kit - nippon life Benefits (medical)



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This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.


Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval.  The following list outlines Nippon Life Benefits' case submission requirements.


- Signed Employer Application for Group Insurance

- Binder-Premium Check - first month's premium based on the sold rate(s)

  • ​​​​Indicate amount to be applied to each division (unit) $_____________

​​​- Completed Policy Issue Checklist (which can be completed electronically)

  •     Electronic Services Agreement
  •     Policyholder Electronic Enrollment Terms and Conditions (if Census is provided)
- Copy of Proposal or plan of benefits requested
- Rate page - with signature for the Plan(s) requested
- Optional Coverage (Must Offer) form (if applicable, form is contained in the formal proposal)
- Census provided on Nippon Life Benefits’ template (available of groups 50+)

- Enrollment forms (with statements of health)
Enrollment forms for employees in the waiting period
- Waivers and reason for waiver for employee and dependents who do not elect coverage
- COBRA Election Forms - if any COBRA participants
- Most recent premium statement for all applicable coverages
- List of employees currently on Disability Continuance and employees currently on FMLA leave
- Tax and Wage forms or K-1 forms (owners/partners) - provide current quarter (not required for 100+enrolled)

  • Indicate part-time (PT) and Terminated (T)
- W-4 forms for any new hire not listed on Tax & Wage

- Copy of prior carrier’s booklet (required for medical 100+ enrolled and for LTD)
- RAQ – Risk Appraisal Questionnaire (groups under 150+enrolled in approved states)

Employer should retain copy of enrollment forms and have form signed prior to the eligibility date
After approval, prior carrier termination letter must be submitted by the employer or broker.

For other useful or older documents, please refer to the Forms database.

Important Reminder: To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website.  For the most recent information regarding Nippon Life Benefits’ SBCs, please go to the SBC Page or contact your Word & Brown Representative.