Group Benefits Inquiry Instructions
Please complete this form and return with a current employee census. Due to healthcare reform, federal law now requires us to collect date of birth and home zip code for the employee and any dependents in order to receive an accurate health insurance quote. Please provide as much detail as possible so we can consider the best options for your company.
Company Name:
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Company Primary Contact:
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FULL Company Address:
*
Contact Phone Number:
*
Contact Email:
*
Company Industry:
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SIC Code:
"NA" If unknown
Do you have any branch offices? If so please list all locations and zip codes here:
*
Type of Business:
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C-Corp
S-Corp
Partnership
LLC
Sole Proprietor
How long have you been in business?
*
How many hours a week must an employee work to be eligible for benefits?
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# of Full-Time Eligible Employees
.
# of Part-Time Non Eligible Employees
.
Do you have any out-of-state employees? If so, please list states below:
Requested plan effective date:
*
Do you currently have a benefits plan in place?
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Yes
No
If yes, please provide copies of your plan summaries and your most recent bill. Also provide your current renewal date.
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What is your desired contribution toward dependent premiums? (i.e. 100%, 50%)
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What is your desired contribution toward employee premiums? (i.e. 100%, 50%)
*
I am interested in the following benefits:
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Medical - PPO Plans
Medical - HMO Plans
Medical - HSA Compatible Plans
Dental
Orthodontic (Add to Dental If Possible)
Vision
Group Term Life
Short Term & Long Term Disability
Flexible Spending Account (FSA)
Health Reimbursement Arrangement (HRA)
Employee Assistance Program (EAP)
Voluntary Worksite Benefits (Accident, Cancer, Hospital Plans)
Employee Wellness Programs
Property Casualty Insurance*
Telemedicine
Identify Theft Protection
Legal Services (Attorney Access)
401k Programs
Do you have any COBRA enrollees? If yes, please indicate on your census.
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Yes
No
Current Property & Casualty Insurance Provider & Renewal Month
*
Name of Payroll Provider
*
What is your pay schedule frequency
*
Select One
Weekly
Semi-Weekly
Bi-Monthly
Monthly
Other
Please upload a current employee census
*
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Submit
Should be Empty: