GROUP HEALTH, LIFE, DISABILITY QUOTE

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General Information Contact Name * Contact Email * Name of Business Nature of Business Address City State Zip Business Phone Fax

Life and AD&D Coverage Number of Employees Number of Employees Eligible Current Carrier Renewal Date Current Rate Renewal Rate Flat Amount

Group Health Coverage Number of Employees Number of Employees Eligible Current Plan HMO  POS  PPO  Indemnity Plan to Quote HMO  POS  PPO  Indemnity Desired Deductible Desired Co-Pay Desired Co-Insurance

Group Dental Coverage Number of Employees Number of Employees Eligible 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 Number of Employees Number of Employees Eligible 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

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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.

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