Site Request Form

Thank you for completing this form to request an MBL site for your client! Please be aware of the following:

Initial site draft turn around is 15 business days from date of request.
All fields are required.
Familiarize yourself with the difference between a base and buy-up site before selecting one. Review the MBL Base vs. Buy-Up Chart
If you have a lot of plan documents to upload, it’s suggested that you create a zip file and upload that.

Site Request Form

Request submitted by:(Required)

Requestor's email:(Required)

Are there additional team members to be notified when the site is ready for review?

Name(s):

Email(s):

Account name:(Required)

BP ID number (found in Client Central on the Details page):(Required)

Producer's first and last name:(Required)

Business Unit:(Required)

Department(Required)

Does the client want the Base or Buy-Up option?(Required)

Base

Buy-Up

How will the site be paid for?(Required)

Invoice Client ($2,500; cost of site compensable)

Client Service Expense ($2,500; cost of site reduces client’s compensable revenue)

Other

How will the site be paid for?(Required)

Invoice Client ($5,000; cost of site compensable)

Client Service Expense ($5,000; cost of site reduces client’s compensable revenue)

Other

Please provide details on fee arrangement

Date to go live:(Required)

MM slash DD slash YYYY

Select which pages should be included in the site:

Eligibility

Enrolling in Benefits

Plan Costs

Retirement

Health Savings Account

Flexible Spending Accounts

Commuter Benefits

Mental Health Resources

Supplemental Medical

Additional Benefits

Choose the site banner image you would like:(Required)

Upload custom image

Upload your banner image:(Required)

Accepted file types: jpg, png, Max. file size: 16 MB.

Must be 1900px wide and between 500px-900px tall. Must be a jpeg or png file.

Enter the client's primary and accent colors.(Required)

Primary Accent

Anything else we need to know to build out the site?

Do you have a Benefits Guide Flipbook? If so, provide link here.

Attachments

Client Logo:(Required)

Please upload any logo files you have.

Drop files here or

Max. file size: 16 MB.

Branding Guidelines:

Please upload any branding documents you have.

Drop files here or

Max. file size: 16 MB.

Plan Documents:(Required)

Please upload the benefits guide, SBCs or and other plan documents. Must be in PDF format.

Drop files here or

Accepted file types: pdf, Max. file size: 16 MB.

Compliance Notices and Other Documents:

Please upload the Compliance Notices and other applicable documents. Must be in PDF format.

Drop files here or

Accepted file types: pdf, Max. file size: 16 MB.

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Need Assistance?

Contact NEB at NEBsystem@alliant.com.