Group Quote Request

Group Name:
Street Address:
Address (cont.):
City:
State:
Zip Code:
County:
Contact Person:
Phone:
Fax:
E-mail Address:
Industry Type:
SIC:
Tax ID:

Answer the Following:

Total number of people on census:		Are there any union employees?	Yes    No
Does the company offer retirement benefits?	Yes    No	Has the company filed Chapter 11 in the past year?	Yes    No
Has the company been active for 5+ years?	Yes   No	Amount (%) paid by employer for employee:
Workers Comp Carrier:		Amount (%) paid by employer for dependents:
Current Carrier:		Requested Effective Date:

Check the Carriers You Would Like to Quote:

Aetna	Health America	United Concordia
American Medical Security (AMS)	Highmark	United Health Care
Fortis	UPMC	Other:

Check Type of Quote Requested:

Group						Voluntary
Health	Vision	Dental	LTD	STD		Dental	Life
Flex 125	401 K	HRA	HSA	Life		STD	LTD
Cobra Administration						Other:

Notes:

Employee Census:

Employee Census must be completed and submitted with this request.

Tier = EE - Employee  EC - Employee & Child(ren)  ES - Employee & Spouse  FM - Family  W - Waiver

* Information only needed for quoting wage based life and disability.

Please include all full time employees whether participation or not.

Out of Area Employees:

Employee Census must be completed and submitted with this request.

Tier = EE - Employee  EC - Employee & Child(ren)  ES - Employee & Spouse  FM - Family  W - Waiver

* Information only needed for quoting wage based life and disability.

Please include all full time employees whether participation or not.