• Benefits at a Glance
  • Request Additional ID Cards
  • Claims Issues
  • Request Physician Directories
  • Add/Remove/Change Employee Benefits
  • Request Materials
  • Cobra Administration

Quote Request for Group Insurance

An * indicates a required field.

*Your Name
*Company Name
City & State
Zip Code
Phone Number
* E-mail Address
Nature of Business
Employee Contribution %
Employee Participation %
HEALTH & DENTAL
YES, we would like a HEALTH Insurance Quote.
YES, we would like a DENTAL Insurance Quote.
LIFE AD&D
Flat Amount for Each Employee
Times Annual Earnings for Each
Employee/Maximum

Classes as Follows:
STD
% of Weekly Earnings Maximum per Week
Day Wait for Accident Day Wait for Sickness
Week Benefit Duration  
LTD
% of Weekly Earnings Maximum per Week
Day Wait for Accident Day Wait for Sickness
Week Benefit Duration  
REQUEST FOR PROPOSAL CENSUS

If you have over 10 employees to enter on the census you can do so by submitting 10 now and then using your browsers back button to return to this form and submitting the additional employees in groups of 10.
Employee # 1
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 2
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 3
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 4
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 5
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 6
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 7
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 8
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 9
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 
Employee # 10
Name SS# DOB Gender
Job Title Salary DOH Class #
Pay Mode* DEP Status** Home Zip
 

 * H - Hourly B - Bi-Weekly W - Weekly M - Monthly A - Annual

** E - Employee Only ES - Employee + Spouse EC - Employee + Child
      F - Full Family
COMMENTS

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