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COMPANY NAME *
ADDRESS: *
CITY & ZIP *
NATURE OF BUSINESS *
EMAIL ADDRESS *
CONTACT *
PHONE NO: *
FAX NO:
PRESENT CARRIER INFO
HOW LONG *
DEDUCTIBLE DESIRED
CO-INSURANCE 80/20 50/50 OR OTHER *
TYPE OF PLAN: HMO - PPO- POS - OR- TRADITIONAL
DENTAL * Yes No
MATERNITY * Yes No
DRUG CARD * Yes No
DOCTOR CALLS * Yes No
STD * Yes No
LTD Yes No
VISION * Yes No
OTHER
PLEASE LIST ANY MEDICAL CONDITIONS WITH-IN THE GROUP
ANYONE HAD MEDICAL BILLS OVER $5000 LAST 12 MO * Yes No
ANYONE RETIRED ON MEDICAL PLAN * Yes No
CURRENT MONTHLY PREMIUM
AMOUNT EMPLOYEE PAYS
RENEWAL RATES
PLEASE LIST EACH EMPLOYEE ON A SEPERATE LINE. STATE THE SEX, DOB, AND EMPLOYEE CODE. EE = EMPLOYEE ONLY************************************ EC = EMPLOYEE & CHILDREN*************************** ES = EMPLOYEE & SPOUSE****************************** EF = EMPLOYEE & FAMILY******************************
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