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CLIENT INFORMATION: |
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Company Name: |
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Street Address: |
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Town: |
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State: |
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ZIP: |
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Type of Business: |
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PREVIOUS INSURANCE: |
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Does you company currently have health insurance in force?
(If No, proceed to the underwriting section) |
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What type of plan do you have now? |
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Does your plan have referrals? |
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What is your current Primary Physician Copay? |
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What is your current Specialist Copay? |
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What is your Hospital Copay? |
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What is your In-Network Deductible? |
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What is your Out-of-Network Deductible? |
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What is your Annual In-Network Maximum Out-of-Pocket? |
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What is your Annual Out-of-Network Maximum Out-of-Pocket? |
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What is your current Prescription Card Copay(s)? |
Generic |
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Name Brand |
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Non
Formulary |
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Current Premium for a Single: |
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Current Premium for an Employee & Spouse: |
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Current Premium for an Employee & Child: |
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Current Premium for an Employee & Children: |
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Current Premium for a Family: |
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UNDERWRITING & COMPLIANCE INFORMATION: |
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In the past 12 months have you had a group health insurance policy lapse
for non-pay? |
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If so, who was the
carrier? |
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How many employees do you have working over 25 hours per week? |
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Do all employees receiving benefits show on your most recent W2 Form? |
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Do employees contribute to their benefit premiums? |
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QUOTE INFORMATION (PROVIDE QUOTE AS
FOLLOWS): |
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***NOTE - Hold down the CTRL key
for multiple selections *** |
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Product Type: |
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Primary Physician Copay: |
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Do you want 100% In-Network hospitalization coverage? |
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In-Network Deductible: |
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Out-of Network Deductible: |
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What is your Annual In-Network Maximum Out-of-Pocket? |
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What is your Annual Out-of-Network Maximum Out-of-Pocket? |
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Vision Rider: |
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Dental Rider: |
Generic |
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Prescription Card Copay(s) : |
Name Brand |
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Non
Formulary |
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When do you need it? |
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CENSUS INFORMATION (IF MORE THAN 25
EMPLOYEES,
CLICK HERE ): |
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Employee Name |
Employee DOB or Age |
Employee Sex |
Contract Type |
Employee Enroll Status |
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Contact's Name: |
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Contact's Phone Number (Include Area Code): |
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Contact's Fax Number (Include Area Code): |
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Contact's E-Mail Address: |
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