Request Information
Personal Information
Proposal Only
Enrollment Material
Contracts
Agent Name:
Agent #:
Address 1:
Address 2:
City:
State:
Zip:
Phone Number:
Fax Number:
Email Address:
Group Information
Group Name:
City
State:
Zip:
Payroll Freq:
# of Eligible Employees:
Type of Business:
Individual Products to be Offered
Disability
Hospital Indemnity / Gap Plans
Benefit Amounts:
Hospital Indemnity:
Yes
No
Does group have Group Major Medical?
Yes
No
What percentage does the employer pay?
What is the group's current deductible?
What is the coinsurance % for hospital stays?
What is the out-of-pocket maximum?
Elim. Period:
Benefit Periods:
50%
100%
0%
Riders:
Yes
No
Cancer Plan / Critical Illness
Accident Plan
Cancer Coverage Only
Accident Plan:
Yes
No
Critical Illness with Cancer Coverage
Disability Rider:
6 months
12months
Critical Illness without Cancer Coverage
Life Plan
3 Employees or More
Term Life
Whole Life
Universal Life
Amount:
STD:
Yes
No
LTD:
Yes
No
Life:
Yes
No
Group Products to Quote
*need census with DOB, sex, & (salary only needed for DI & Life)
Dental:
Yes
No
Vision:
Yes
No
I need proposal or enrollment material no later than:
I would like proposal:
Faxed
E-Mailed
Mailed
