In order for us to provide you with a proposal, the following information must be completed. The
more information we have, the better we are able to make a valid assessment of your benefits
package. In many instances we will be the right fit for you and your employees and in some
instances we may not. We will do our best to arm you with the information needed to make a
sound decision with regard to your employee benefits package.
Company Information
Company Name:
Contact Person:
Address:
City:
State:
Zip:
County:
Phone:
Fax:
Email:
Common Ownership:
Yes
No
Standard Industry Code or Industry Type:
Current Association (if a member):
Current Carrier Information
Plan Type:
Medical
Dental
Vision
Current Insurance Carrier:
Effective Date:
Current Plan:
Plan Type:
Medical
Dental
Vision
Current Insurance Carrier:
Effective Date:
Current Plan:
Plan Type:
Medical
Dental
Vision
Current Insurance Carrier:
Effective Date:
Current Plan:
Are you interested in receiving a quote for the following?
Group Life/AD&D
Yes
No
Group Short Term Disability
Yes
No
Group Long Term Disability
Yes
No
Long Term Care
Yes
No
Group Retirement Plans
Yes
No
Individual Life/AD&D
Yes
No
Individual Retirement Plans
Yes
No
Additional information will be requested if you check yes to any of the above.
The below data can also be emaild via an excel spreadsheet
Last Name
Occupation
Salary*
(needed for STD, LTD and/or specific Life Proposal)
Gender (m/f)
DOB
Home Zip
Coverage Tier
(individual, parent/child, parent children, two person, famil, waived & why, cobra & coverage level, Medicare eligibles)