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):
Small Group
Individual/Family
Dental
Vision
LTD
STD
Life/AD&D
Company Information
Company 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
Address(cont.):
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
Company contributions (if applicable):
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 Group 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
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
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