Group Insurance Quote

Name of Business (*)
Contact Name (*)
Email (*)
Phone (*)
Nature of Business
Mailing Address
City
State
Zip


Life and AD&D Information
Number of employees
Number eligible
Current carrier
Renewal date
Current rate
Renewal rate


Amount of Death Benefit
Flat Amount
Multiple of Earnings
Schedule
Employee census information including date of birth, gender and job title/earnings or coverage comments will be required. Loss information will be helpful and may be required on groups over 100 lives.
Describe any pre-existing health conditions
Please note any other pertinent information or requests for coverage


Group Health Coverage
Number of Employees

Number Eligible

Current Plan

Plan to Quote

Desired Deductible

Desired Co-Payment

Desired Co-Insurance
Describe any pre-existing health conditions

Please note any other pertinent information or requests for coverage

Employee census information including date of birth, gender, location and family status will be required. Loss information, including shock loss, will be helpful and may be required on groups over 100 lives.


Group Dental Coverage
Number of Employees

Number Eligible

Calendar Year Max Co-Insurance
Class A Deductible

Class B Deductible

Class C Deductible
Class A Co-Insurance

Class B Co-Insurance

Class C Co-Insurance
Orthodontia  Yes No

Describe any pre-existing health conditions

Children under 19  Yes No

Please note any other pertinent information or requests for coverage


Group Disability Coverage
Number of Employees

Number Eligible
Current carrier
Renewal date
Current rate
Renewal rate
Coverages Desired  STD LTD
Benefits to be Quoted
STD Elimination Period

STD Percentage Payable

STD Maximum Benefit

STD Duration Benefits
LTD Elimination Period

LTD Percentage Payable

LTD Maximum Benefit

LTD Duration Benefits
Describe any pre-existing health conditions
Please note any other pertinent information or requests for coverage
Employee census information including date of birth, gender, job title and earnings will be required. Loss information will be helpful and may be required on groups over 100 lives.

Additional Comments