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Request for a Group Insurance Quote

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By completing and submitting this form, you agree that no coverage is bound and no policy is in effect until you are contacted by one of our agency representatives. All information submitted is held in the strictest confidence and is only gathered for the purposes of providing you an insurance quote. To provide the most accurate quote possible, please complete all areas that apply.
General Information
Name of Business
Street Address
City
State
ZIP Code
Contact Person
Business Telephone
Nature of Business
Life and AD&D Coverage
Number of Employees
Number Eligible
Current Carrier
Renewal Date
Current Rate
Renewal Rate
Amount of Death Benefit
Flat Amount
Multiple of Earnings
Schedule
Employee census information including date of birth, gender and job title/earnings or coverage comments will be required. Loss information will be helpful and may be required on groups over 100 lives.
Describe any pre-existing health conditions:
Please note any other pertinent information or requests for coverage:
Group Health Coverage
Number of Employees
Number Eligible
Current Plan HMO   POS   PPO   Indemnity
Plan to Quote HMO   POS   PPO   Indemnity
Desired Deductible
Desired Co-Payment
Desired Co-Insurance
Describe any pre-existing health conditions:
Please note any other pertinent information or requests for coverage:
Employee census information including date of birth, gender, location and family status will be required. Loss information, including shock loss, will be helpful and may be required on groups over 100 lives.
Group Dental Coverage
Number of Employees
Number Eligible

Deductible

 Co-Insurance
Class A
Class B
Class C
Calendar Year Maximum
Orthodontia Yes   No  Children under age 19
Describe any pre-existing health conditions:
Please note any other pertinent information or requests for coverage:
Group Disability Coverage
Number of Employees
Number Eligible
Coverages Desired STD   LTD
Current Carrier
Renewal Date
Current Rate
Renewal Rate
Benefits to be Quoted
  STD LTD
Elimination Period
Percentage Payable
Maximum Benefit
Duration Benefits
Employee census information including date of birth, gender, job title and earnings will be required. Loss information will be helpful and may be required on groups over 100 lives.
Describe any pre-existing health conditions:
Please note any other pertinent information or requests for coverage:
Additional Comments
 

 

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