Provident New Business Questionnaire

Emergency Service Organization New Business Underwriting Questionnaire
Provident - Main Office:

PO Box 11588

Pittsburgh, PA 15238

Phone: 412.963.1200

Email: benefits@providentins.com

www.providentins.com

Business Hours: 8:30 AM to 5 PM

Please note, this document could take up to 10+ minutes to complete. If you wish to start filling it out now, you can always press "Save & Continue Later" at the bottom of this form to complete and submit at a later time.

NOTE: Coverage is subject to exclusions and limitations and may not be available in all US states and jurisdictions.
Instructions:
- In order to reserve a proposal for any Emergency Service Organization product, Sections 1 and 2 must be completed in full. This reservation will be good for 90 days from the date of submission or until the date proposals are needed, whichever is longer.
- Section 3 must be completed in full in order to receive a proposal for any policy type.
- In order to obtain an Accident & Health proposal, Sections 4a and 4b must also be completed in full.
- In order to obtain a proposal for other group products, please complete Section 5 and/or 6 and/or 7. Also, include a roster for Group Term Life and Group Critical Illness proposals.
- Please do not leave blanks. Use N/A or zero if necessary.
Once you have completed this questionnaire, press "Submit" at the end of the form and it will automatically get emailed to benefits@providentins.com. You will receive an email with your entry data and an attached finalized PDF with the data. Thank you for your cooperation!
Please identify who is filling out this New Business Questionnaire:*
Date of New Business Submission*

MonthDayYear
Date Proposal(s) Needed*

MonthDayYear
Which policies would you like to propose?*

Accident & Health (A&H)Accidental Death & Dismemberment (AD&D)Group Term Life (GTL)Group Critical Illness (GCI)
General Policyholder Information
Policyholder Full Name (as it should appear on a policy)*
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physical Address County *
Mailing Address (check if same as above)
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState

Zip Code
Organization/Department Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Organization/Department Fax
Please enter a valid phone number.Format: (000) 000-0000.
Organization/Department Website
Organization/Department Contact Person FIRST NAME*
First Name
Organization/Department Contact Person LAST NAME*
Last Name
Organization/Department Position*
Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Organization/Department Contact Email*
example@example.com

Broker Information
Agency Name*
Agency Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Agency Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Agency Fax
Please enter a valid phone number.Format: (000) 000-0000.
Agency Website
Broker First Name*
First Name
Broker Last Name*
Last Name
Broker Life, Accident & Health License #
Broker Mobile Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Broker Email*
example@example.com
CSR Fist Name
First Name
CSR Last Name
Last Name
CSR Phone
Please enter a valid phone number.Format: (000) 000-0000.
CSR Email
example@example.com

Rows	Number of Runs
Fire and other non-medical runs
Emergency medical or first responder medical
Non-emergency transports

Rows	Number of Vehicles
Fire
Rescue
Ambulance
Other

Accident & Health Policy and Benefit Information
Current Insurance Carrier*
Current Effective Date

MonthDayYear
Current Premium*
Desired Effective Date

MonthDayYear
Current Pay Mode:

1-year annual payment3-year annual installment payment3-year prepaid payment
File Upload

Please upload Benefit Declaration Pages and 5-year loss history, if available.
Cancelof
Current A&H Benefit Limits
Covered Injury Death Benefit
Covered Illness Death Benefit
Weekly Total Disability Benefit
Weekly Total Disability Benefit Duration
Number of years
Medical Expense Benefit
Daily Hospital Confinement Benefit

Desired A&H Benefit Limits (Fill in at least one plan aka one full row)*

Rows	Death Benefit ($5,000 - $500,000)	Weekly Disability ($50 - $1,000)	Medical Expense ($2,500 - $250,000)
Plan 1
Plan 2
Plan 3

Does the organization participate in Organized League Athletics?*

YesNo
If yes, would the organization like organized league athletic coverage included in the proposal?

YesNo
Type of sport
Number of participants
Start date

MonthDayYear
Length of season
League Athletics

Option 1 includes: Death Benefit $5,000, Accident Medical Expense $2,500, Daily Accident Indemnity $15Option 2 includes: Death Benefit $10,000, Accident Medical Expense $5,000, Daily Accident Indemnity $30
Additional Notes

Group Term Life
In order to receive a quote for this product, a roster that includes the name, date of birth, gender and volunteer/career status for all members who are to be covered is required. You can upload the roster in the File Upload below - this is a secure upload portal.
Current Carrier*
Current Policy Premium*
Current Benefit Amount
Desired Benefit Amount
Current Effective Date

MonthDayYear
Desired Effective Date

MonthDayYear
Number of Members to be Covered
Age Reduction Schedule*

No Age ReductionStandard Age Reduction (50% at age 70)Other
Roster File Upload

Cancelof

Group Critical Illness
In order to receive a quote for this product, a roster with names and dates of birth for all members is required. Coverage is available to members younger than 75 years old. You can upload the roster in the File Upload below - this is a secure upload portal.
Benefits amounts currently offered are $10,000, $20,000 and $30,000. This product is not available in all states.
Number of Members to be Covered*
Desired Effective Date

MonthDayYear
Roster File Upload

Cancelof

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Emergency Service Organization New Business Underwriting Questionnaire

Instructions:

General Policyholder Information

Broker Information

Emergency Service Organization Information

General Underwriting Information

Who is covered by Workers’ Compensation (WC)?

Accident & Health Policy and Benefit Information

Current A&H Benefit Limits

Accidental Death & Dismemberment

Group Term Life

Group Critical Illness