Custom Open Enrollment Video Form

To create the custom link for the Open Enrollment video, enter their information below. 
 
A link won't be generated until you click SUBMIT.
 
Once SUBMIT has been clicked, you can view the proof of their dynamic personalized messages on the right hand side.
If you need to make an update, make the change and click SUBMIT again.
 
ATTENTION – Reserved Characters not to use in this form: \ # [ ] @ & < > { } | ^
 
A or An* (before the client name: an Apple employee)
Organization*
Employee Type*
Plan Option 1*
Other*
(If Plan Option 1 is Other, please enter your custom Plan Name)
Frame Allowance* 
($ sign will automatically be added.)
Conjunction* 
(For Frame and/or Contact Allowance)
Contact Allowance* 
($ sign will automatically be added.)
Featured Frame Allowance* 
(Enter frame allowance without $ sign)
Plan Option 2
Other*
(If Plan Option 2 is Other, please enter your custom Plan Name)
Frame Allowance*
($ sign will automatically be added.)
Conjunction* 
(For Frame and/or Contact Allowance)
Contact Allowance*
($ sign will automatically be added.)
Featured Frame Allowance*
(Enter frame allowance without $ sign)
Plan Option 3
Average Savings*  (Enter savings without $ sign)
Exam Copay* (Enter copay without $ sign)
Plan Frequency* (Enter number of Months)
"Save The Date" Custom Message*  
(HTML Compatible, use single quotes)
Custom enrollment message*  
(HTML Compatible, use single quotes)
Location URL of embedded video*  

Proof of Dynamic
Personal Messages

Please enter your information into the fields
and click SUBMIT to review personal messages.