Please complete as much of the following information as possible. Be sure to list a valid e-mail address and phone number so we can contact you if we have any questions. Contact Information First Name:        Last Name:  Phone:     Fax:     Email:  I'm interested in the following group plans (Check all that apply): Medical Dental Vision Long-term Disability Short-term Disability Life/AD&D School Information School Name:   Address:  City:     State:   CA AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY    Zip:   URL:  Eligible Participants:      Number Participating:  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 School contributions: Employee:  0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 %      Dependent:  0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 % Census Information Or, to upload a census file, click browse and find file:       Medical Insurance Information I'm interested in a quote for (Check all that apply): HMO PPO POS Do you have current group coverage? Yes No Renewal date for current coverage (mm/dd/yyyy): Current plan(s) in force(Check all that apply): HMO PPO POS Current carrier(s): Medical Questions To the best of your knowledge: Are any participants or dependents pregnant? Yes No Has anyone been confined to a hospital in the past 24 months? Yes No Are any participants currently disabled? Yes No Has anyone incurred $2,500 or more in medical expenses in the past 12 months? Yes No Is anyone receiving treatment or has been treated for cancer, stroke, heart, kidney, or a circulatory disorder? Yes No Does any one take any prescription drugs at this time ? Yes No Dental Insurance Information I'm interested in a quote for (Check all that apply): DHMO DPPO Indemnity Do you have current group coverage? Yes No Renewal date for current coverage (mm/dd/yyyy): Current plan(s) in force(Check all that apply): DHMO DPPO Indemnity Current carrier(s): Vision Insurance Information Do you have current group coverage? Yes No Renewal date for current coverage (mm/dd/yyyy): Current carrier: Long-term Disability Insurance Information Do you have current group coverage? Yes No Renewal date for current coverage: Elimination Period (in days): 60 90 Other  Monthly Benefit: % to $ Benefit Period: 24 Months Age 65 Other  Short-term Disability Insurance Information Do you have current group coverage? Yes No Renewal date for current coverage: Elimination Period (in days): 7 14 Other  Weekly Benefit: % to $ Benefit Period:  Weeks Basic Life and Accidental Death & Dismemberment (AD&D) Insurance Information Do you have current group coverage? Yes No Renewal date for current coverage: Death Benefit: Flat amount $ Times annual salary (1x, 2x, etc.)   Comments or Questions: Submit      Reset

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