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 InfoBroker Name First Last Agency:PhoneFaxEmail Client InfoName First Last Type of Business or SIC:Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Effective Date MM DD YYYY Needed by:Current Dental Plan DesignCurrent Carrier:In-NetworkPreventative %Basic %Major %Ortho %Out-of-NetworkPreventative %Basic %Major %Ortho %Deductible: $Does it apply to preventative / diagnostic?YesNoAnnual Benefit: $Per person / Per yearOrthodontic: $Lifetime Max.Current RatesSingle:Employee + 1:Employee + Children:FamilyRenewal RatesSingle:Employee + 1:Employee + Children:FamilyContributionSingle Rate: $Employee Contribution: $Employer Contribution: $Dependent Rate: $Employee Contribution: $Employer Contribution: $Current ParticipationTotal Number of Employees:Number of Employees in Plan:Life & Disability QuotesCurrent Group Life Carrier:Current STD/LTD Carrier:Requested Plan DesignSTD % 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 InsuranceSalary XFlat Amount $Census EntryIf 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 EntryCensus FileAccepted file types: pdf, txt, doc, xls, jpg.You can upload a census file securely with this form. File types: PDF, TXT, DOC, XLS, JPGCaptcha
