Group Quote Request

Group Benefits Quote Request

Please complete this group census as much as possible so that we can better analyze your needs. NOTE: not all fields are necessary, but more information will give you a better proposal.

Broker Info
Broker Name
First Last
Agency:
Phone
Fax
Email
Client Info
Name
First Last
Type of Business or SIC:
Address
Street Address City State ZIP Code
Effective Date
MM
DD
YYYY
Needed by:
Current Dental Plan Design
Current Carrier:
In-Network
Preventative % Basic % Major % Ortho %
Out-of-Network
Preventative % Basic % Major % Ortho %
Deductible: $
Does it apply to preventative / diagnostic?
- Yes
- No
Annual Benefit: $
Per person / Per year
Orthodontic: $
Lifetime Max.
Current Rates
Single:
Employee + 1:
Employee + Children:
Family
Renewal Rates
Single:
Employee + 1:
Employee + Children:
Family
Contribution
Single Rate: $
Employee Contribution: $
Employer Contribution: $
Dependent Rate: $
Employee Contribution: $
Employer Contribution: $
Current Participation
Total Number of Employees:
Number of Employees in Plan:
Life & Disability Quotes
Current Group Life Carrier:
Current STD/LTD Carrier:
Requested Plan Design
STD % of Earnings
- 60%
- 66.67%
- 70%
STD Benefit Period
- 13 Weeks
- 26 Weeks
LTD Elimination Period
- 90 Days
- 180 Days
LTD Maximum Monthly Benefit $
Group Life Insurance
Salary X Flat Amount $
Census Entry
If you are requesting a Life or DI quote, please include Census Data with M/F, DOB, salary, and class ~or~ Fax census to 603-418-0853 and refer to online request in Subject.
Census Entry
Census File
Accepted file types: pdf, txt, doc, xls, jpg.
You can upload a census file securely with this form. File types: PDF, TXT, DOC, XLS, JPG
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Group Benefits Quote Request

Broker Info

Client Info

Current Dental Plan Design

Current Rates

Renewal Rates

Contribution

Current Participation

Life & Disability Quotes

Requested Plan Design

Census Entry

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