Your Name (required)

Title

Your Email (required)

Full Legal Name of Business

Street Address

Street Address Cont.

City

State NoneAlabamaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

zip

Work Number

Email Address

Best Time to Contact

Group Profile

Current Census Data including: dob/age, male/female and single/family. ---I'll email the censusI 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

Benefit Description

Schedule of current plan benefits

Any recent or future plan revisions

Experience

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

Contract Type NoneSpecific12/1212/1515/12Paid

Aggregate NoneSpecific12/1212/1515/12Paid

Benefits to be covered under aggregate NoneMedicalDentalVisionRX

Aggregate accomodation NoneYesNo

Life time max None1,000,0002,000,0005,000,000

Timeline

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.

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