Your Name (required)
Title
Your Email (required)
Full Legal Name of Business
Street Address
Street Address Cont.
City
State None Alabama Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
zip
Work Number
Email Address
Best Time to Contact
Current Census Data including: dob/age, male/female and single/family. --- I'll email the census I will call before sending the census
Age bracketed census (if available)
Type of business
Number of locations
Number of employees
Number of subsidiaries
SIC Code
Effective Date
Schedule of current plan benefits
Any recent or future plan revisions
Minimum two years of premium and claims experience
Month by month with employee counts by month
Renewal rates
Details of any shock claims or large pending claims
Any employee or dependent disabled or not actively at work
Is plan contributory? If so, what percentage?
Group life insurance information, if required
Are retiree lives covered, if so, provide details.
Is Group currently fully insured?
Is the Group partially self-insured? If yes, how many years?
Contract Type None Specific 12/12 12/15 15/12 Paid
Aggregate None Specific 12/12 12/15 15/12 Paid
Benefits to be covered under aggregate None Medical Dental Vision RX
Aggregate accomodation None Yes No
Life time max None 1,000,000 2,000,000 5,000,000
Date quote is needed
If you have any questions as to why we are requesting any specific item listed above, please call us at 800-680-0892. If you are mailing the information to us, use the address listed below.
