OneAmerica Financial® Employee Benefits Quote Request
Please complete the form below to request a quote for Life/AD&D, Short-Term Disability (STD), and Long-Term Disability (LTD) coverage. Items to note: 1. Some SIC codes are ineligible for coverage; we will review and communicate after submission 2. For groups under 10 lives, family content of covered individuals must be less than 50% 3. Businesses in operation for less than two years may be ineligible for coverage; we will review and communicate after submission
This process takes less than 5 minutes. Please answer all questions.
Company Info
Company Name
*
City
*
State
*
Industry Type / SIC Code (preferred)
*
Total Employees
*
Desired Effective Date of Coverage
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How many years have you been in business?
*
Payroll Frequency
*
Please Select
Weekly
Biweekly
Semi-Monthly
Monthly
Company Contact Name
*
Company Contact Email
*
example@example.com
Company Contact Phone
*
Do you currently work with a benefits broker?
*
Please Select
Yes
No
If Yes, please list the name of the broker contact.
If Yes, please list the email address of the broker contact.
Coverage Requested (IMPORTANT)
Life Insurance Coverage
*
Please Select
Employer Paid Basic
Employer Paid + Employee Paid
Employee Paid Only
Not interested
If Employer Paid Life is requested, do you want:
*
Please Select
$10,000 Life/AD&D
$20,000 Life/AD&D
$50,000 Life/AD&D
Short Term Disability (STD) Coverage
*
Please Select
Employer Paid
Employee Paid
Not Interested
STD plan is 60% to $1,500/week with a 14/14 elimination period. Choose the desired STD benefit duration
*
Please Select
13 weeks
26 weeks
Long Term Disability (LTD) Coverage
*
Please Select
Employer Paid
Employee Paid
Not Interested
LTD plan is 60% to $6,000/month. Choose the desired LTD benefit elimination period
*
Please Select
90 Days (choose if electing 13 week STD benefit duration)
180 Days (choose if electing 26 week STD benefit duration
Anything else you'd like us to know:
Census Upload
Upload Employee Census (Excel ONLY. Should include: Employee Name, Date of Birth, Gender, Date of Hire, Occupation, # of Hours Worked/Week and Annual Earnings)
*
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