GENERAL DEMOGRAPHIC INFORMATION

Fields highlighted in red must be filled in.
Company:
Contact Name:
Title:
Address:
City:
County:
State:
Zip Code: (+4 optional)
E-mail:
Web Site URL:
Telephone:
Fax:
List other locations where employees will be covered:
Type of business:
SIC Code:
Total Full Time Employees:
Total Enrolled Employees :

CURRENT MEDICAL PLAN DESIGN/BENEFITS

Renewal Date:
Current Carrier:
How long have you been with your current carrier?
What type(s) of managed care program(s) do you currently utilize?(Click all that apply.)
Health Maintenance Organization(HMO)
Preferred Provider Organization(PPO)
Coinsurance percentage when using an in-network physician:
Coinsurance percentage when using an out-of-network physician:
Network Deductibles:
Out-of-Network Deductibles:
Network Maximum Out-of-Pocket:
Out-of-Network Maximum Out-of-Pocket:
CoPays:
Prescription CoPays:
Who's covered:
Yes No
Yes No

CURRENT PREMIUM COSTS

Employee Only (EE):
Employee & Spouse (E+S):
Employee & Children (E+C):
Family (FF):

CURRENT CONTRIBUTION TO PREMIUM COSTS

Employee percentage contribution to monthly premium for:

RENEWAL PREMIUM COSTS

Employee Only (EE):
Employee & Spouse (E+S):
Employee & Children (E+C):
Family (FF):

OTHER COVERAGES

Do you provide Dental?
Yes
No
What is the deductible amount?
What percentages are covered for the following services:
Do you want a Short Term Disability quote?
Yes
No
Do you want a Vision quote?
Yes
No
Do you want a life insurance quote?
Yes
No
If yes, how much coverage per employee?

Additional Comments

When finished adding information, please click the "Send Information" button below. You will be directed to a page that provides options about how you want to provide your enrollee information.

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