Number of Employees:
Number of Eligible Employees:
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 Eligible Employees:

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 Eligible Employees:
Current Plan:
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.