Group Quote

Contact Name: *

Contact Email: *

Name of Business: *

Nature of Business: *

Number of Employees: *

Number of Employees on Group Plan: *

Address: *

City: *

State: *

Zip: *

Business Phone: *

Fax:

Employer Premium Contribution Percent:

Group Health Coverage

Do Not Quote Health

Current Carrier: *

Coverage Type (click all that apply): *

HMO

Point of Sale

PPO

Renewal Date: *

Life and AD&D Coverage

Do Not Quote Life and AD&D

Current Life Amount: *

Current Carrier: *

Dependent Life Offered:

Yes

Group Dental

Do Not Quote Group Dental

Current Carrier: *

Renewal Date: *

Group Disability Coverage

Do Not Quote Group Disability

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Do Not Quote Short Term Disability

Do Not Quote Long Term Disability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, Sex, Job Title, and Earnings 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.