Quote Request.pdf
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Printable version of this document
Online Quote Request
Company Information
Company Name:
Contact:
Effective Date:
Location:
# of Locations:
Email Address:
Phone:
Nature of Business:
Fax:
Preferred Network:
Ind. SIC Code:
Current Coverage
Type of Plan:
Fully Insured
Self-Funded
Minimum Premium
Carrier and/or Administrator:
Self-Funded, contract basis:
Employer contribution:
Employee
% Dependents
%
Requested Coverage (Specific)
Annual Deductible Amount:
12/12: Incurred and paid within the policy period
15/12: Incurred within the policy period or 90 days immediately prior and with policy period
12/15: Incurred within the policy period and paid within policy period or within 90 days
Other:
Requested Coverage (Aggregate)
12/12: Incurred and paid within the policy period
15/12: Incurred within the policy period or 90 days immediately prior and with policy period
12/15: Incurred within the policy period and paid within policy period or within 90 days
Other:
Coverage Options:
Aggregate Accommodation
Terminal Extension
Benefits
Medical:
Yes
No
Prescription Drug Card:
Yes
No
Dental:
Yes
No
Vision:
Yes
No
Short Term Disability:
Yes
No
Current Enrollment
Total Number of Employees Eligible:
Total Number of Employees Participating:
Employee Coverage Count:
Employee/Spouse Coverage Count:
Employee/Child(ren) Coverage Count:
Family Coverage Count:
Rates and Factors (Current)
Rates
Fully Insured Rates or Aggregate Factors
Specific
Aggregate
Medical
Rx Card
Dental
Employee
EE/SP
EE/CH
Family
Rates and Factors (Renewal)
Rates
Fully Insured Rates or Aggregate Factors
Specific
Aggregate
Medical
Rx Card
Dental
Employee
EE/SP
EE/CH
Family
In order to process a quote we will need the following items:
• Current Plan Document noting any changes you would like to make
• Current Census stating age, sex, and coverage status
• Claims experience for the past 3 years preferred (minimum 2 years)
• Any medical claim(s) exceeding 50% of requested specific deductible
