GROUP HEALTH QUOTE REQUEST
General Information
Contact Name:
Contact E-Mail:
Business Name:
Business Nature:
Address:
City:
State:
Zip:
County:
Phone:
Fax:
Life and AD&D Coverage
Employees:
Eligible Employees:
Current Carrier:
Renewal Date:
Current Rate:
Renewal Rate:
Flat Amount:
Group Health Coverage
Employees:
Eligible Employees:
Current Plan:
HMO POS
PPO Indemnity
Plan to Quote:
HMO POS
PPO Indemnity
Desired Deductible:
Desired Co-Pay:
Desired Co-Insurance:
Group Dental Coverage
Employees:
Eligible Employees:
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
Employees:
Eligible Employees:
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.

The premiums quoted are estimates based on provided information. Quote 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.