Group Health, Life & Disability Form
 
 General Information
  Contact Name *
  Contact Email *

  Name of Business
  Nature of Business
  Address
  City
  State
  Zip
  Business Phone
  Fax
 
 Life and AD&D Coverage
  Number of Employees
  Number of Employees Eligible
  Current Carrier
  Renewal Date
  Current Rate
  Renewal Rate
  Flat Amount
 
 Group Health Coverage
  Number of Employees
  Number of Employees Eligible
  Current Plan HMO  POS  PPO  Indemnity
  Plan to Quote HMO  POS  PPO  Indemnity
  Desired Deductible
  Desired Co-Pay
  Desired Co-Insurance
 
 Group Dental Coverage
  Number of Employees
  Number of Employees Eligible

  Class A Deductible
  Class B Deductible
  Class C Deductible

  Class A Co-Insurance
  Class B Co-Insurance
  Class C Co-Insurance
  Calendar Year Maximum
 
 Group Disability Coverage
  Number of Employees
  Number of Employees Eligible
  Current Plan STD  LTD
  Current Carrier
  Renewal Date

  Current Rates STD
  Renewal Rates STD
  Elimination Period STD
  Percentage Payable STD
  Maximum Benefit STD
  Duration Benefits STD

  Current Rates LTD
  Renewal Rates LTD
  Elimination Period LTD
  Percentage Payable LTD
  Maximum Benefit LTD
  Duration Benefits LTD
 
 Comments
  Employee census information including Date of Birth, Sex, Job Title and Earnings will be required. Loss Information will be helpful and may be required on groups over 100 lives.
  Please note any other pertinent information or requests for coverages
  * indicates required fields
 
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.