1. What percentage of your medical premium is contributed by the employer?
Employees (minimum 50%):
Dependents (no minimum):
2. What percentage of your dental premium is contributed by the employer?
Employees (minimum 50%):
Dependents (no minimum):
Requested Effective Date:
ELGIBILITY:
1. How many hours per week must employees work to be elgible for benefits?
Minimum 17.5 hrs/week:
2. What is the elgibility period employess must complete before being eligible for benefits?
The first of the month following:
3. Domestic Partner Coverage:
Not Currently Offered
Same Sex
Opposite Sex
Either Sex
EXISTING PLAN DATA (If applicable):
Current Carrier:
Plan Deisgn (deductible level, co-pays, etc.):
RATES
Employee
Employee + Spouse
Employee + Family
Employee + Child(ren)
Medical
Dental
EMPLOYEE DATA:
Instructions: Please list all current active employees. This includes; owners, sole proprietors, partners, of a partnership, independent contractors (only if included as a permanent employee on your payroll with an exclusive relationship with you) and part-time employees.
Enrollment Legend
Family Enrollment Status
Other Status
01 = Employee Only
W = Waiving to Other Group Coverage
02 = Employee + Spouse
NE = Not Enough Hours to Qualify
03 = Employee + Children
NP = Has not Served Waiting Period
04 = Employee + Family
C = Cobra/Continuation Employee
Last Name
Gender
Date of Birth
Spouses's
Date of Birth
Residential
Zip Code
Enrollment
Status
(See Legend)
Number of Children
and the Age of Each
Hours
Worked
per Week
1.
2.
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25.
ADDITIONAL COMMENTS AND REMARKS:
Who were you referred by?
Are you already working with one of our agents?
Yes
No
If yes, who?
Please enter any additional comments:
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quote 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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