May 19, 2013
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Request an Employee Benefits Quote
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
* = Required Field
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.
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