Group Quote

General Information

Contact Name: *

Contact Email: *

Name of Business: *

Nature of Business: *

Number of Full-time Employees/ FTE's (Part time, seasonal, variable): *

Number of Employees on Group Plan: *

Address: *

City: *

State: *

Zip: *

Business Phone: *

Fax:

Contribution:

Group Health Coverage

Current Carrier: *

Renewal Date: *

Life and AD&D Coverage

Current Life Amount: *

Current Carrier: *

Renewal Date: *

Dependent Life Offered:

Yes

Group Dental

Current Carrier: *

Renewal Date: *

Group Disability Coverage

Current Carrier: *

Renewal Date: *

Do Not Quote Short Term Disability

Do Not Quote Long Term Disability

Elimination Period: *

Percentage Payable: *

Maximum Benefit: *

Comments

Employee census information including Date of Birth, Gender, Zip Code,Whether or not the single or family. If family, we will need dependent information, Job Title, and Salaries (for disability quotes) will be required. Loss Information will be helpful and may be required over 100 lives.

Please note any other pertinent information or requests for coverages.

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.