Quote request form
Applicant Information
Exposure Information
Historical Information
Coverage Availability
Employer-paid coverage
Number of employees
Life
LTD
STD
(1)
Dental
(1)
Vision
(1)
2+
X
(2)
X
(2)
X
(2)
X
(2)
X
(2)
Voluntary coverage
Life
LTD
STD
Dental
Vision
CriticalI
llness
(3,4)
Accident
(1)
Greater of 5 enrolled employees or 20% participation (5 or 10% for critical illness and accident).
Participation requirements may be waived for qualified groups with 5-499 eligible employees.(5)
(1) Self-funded coverage is available to employers with 100+ employees and at least one insured coverage
(2) Requires 2+ coverages for groups with 2-4 employees
(3) Must be sold with another coverage
(4) Specified disease in NY
(5) A minimum of 2 enrolled employees per voluntary coverage required. (In NY, 50% of eligible employees or 5, whichever is fewer.)
Group Name
Coverage Effective Date
Quote Need By Date
Years in Business
SIC Code (Lookup Code)
Web Address
Primary Business Activity of the Firm & Description of Operations
Home Office Street Address
State
Zip
Mailing Address if different
State
Zip
+ Add row for additional operating locations
Primary Company Contact
Name
Phone
Email
HR Contact
Name
Phone
Email
Producer
Name
Phone
Email
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Quote request from
Applicant Information
Exposure Information
Historical Information
Please provide an employee census
Employee Name
DOB
Gender
M
W
Zip Code of Residence
Spouse
Yes
No
Children
Check if employee has life or dental insurance
Life visual
Dental
+ Add row for additional employee
Company Policies & Important Numbers
Number of hours per week for an employee to be full time and eligible for insurance coverage. Can be 17.5 to 40 hrs
The required probationary or waiting period after an employee starts working full time. Can be 0 to 90 days
Percentage of the premium for the employee-only portion you are planning to contribute. Must be 50% or more
Percentage of the premium for the dependent portion you are planning to contribute, if any. May be 0% or 100%
Total number of full and part-time employees working for the company. For deferral HIPAA & COBRA applicability
Total number of employees working over 17.5 hours per week on a regular basis.
Total number of employees meeting full time work requirements, whether coming on the plan or not
Total number of employees who are planning to enroll for insurance on the planned effective date of the plan
Average number of employees, employed in the prior calendar year
Do you intend to cover all employees?
Yes
No
If No, do you intend to cover one or more classes?
Yes
No
Classes must be based on bona fide employment based classifications consistent with your usual business practice. Employers with 25 or fewer employees must cover all eligible employees
Company Policies & Important Numbers
Health Insurance
Prescription Drug Coverage
Dental
Short-term Disability
Long-term Disability
Group Life
Other
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Quote request from
Applicant Information
Exposure Information
Historical Information
Please provide historical coverage information
Year
Product
Last 3 years experience
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# lives insured
Rate
Requested commission
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Open Claims
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Please provide historical coverage information
Physician co-payment
Deductible or Hospital Admin
Coinsurance Percentage
Stop-Loss or Out of Pocket
Any other features important to you?
Stop-Loss or Out of Pocket
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Current Benefits
Health Insurance
Prescription Drug Coverage
Dental
Short-term Disability
Long-term Disability
Group Life
Other
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