Group Employee Benefits Information Request Form

(Life, Health, HSA, Disability, Dental and Voluntary Products)

Contact Information                                                       * Required Fields
	* Company Name:
	* First Name:
	* Last Name:
	* Your Address:
	* City:
	* State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New York New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wyoming Wisconsin Washington D.C.
	* Zip Code:
	* Work Phone Number:		-   Ext.
	Alternate Number:		-
	* Best time to contact you:		Select Morning / Home Morning / Office Afternoon / Home Afternoon / Office Evening / Home Evening / Office
	* Your E-mail Address:
General Information
Type of Company?			Sole Proprietor Corporation - C Company - LLC Partnership S-Corporation
Do you currently have Business Group Health?			Yes No
	If yes, when does current policy expire?
	Current Insurance Carrier:
Type of Business:
	Description of Business Operations:
Number of Locations:
* Number of Employees:			---- Select ---- 1- 5 employees 6- 9 employees 10 - 19 employees 20 - 29 employees 30 - 49 employees 50 or more
	Number of Employees Currently Participating In Plan:
Current Plan Information (or what you would like to see)
Type of Health Plan:			---- Select ---- HMO PPO/ POS Medial Savings Account Not Sure
Current Deductible or Hospital Admission Fee:			---- Select ---- $250 $500 $750 $1000 $1500 $2000
Current Co-Insurance Percentage:			---- Select ---- 80/20 90/10 70/30 60/40 50/50
Office Visit Co-Pay?			Yes No
	If yes, Co-Pay Amount:
Prescription Drug (RX) Co-Pay?			Yes No
	If yes, Co-Pay Amount:
Dental Plan In Place?			Yes No Want Dental? Yes No
Vision Plan In Place?			Yes No Want Vision? Yes No
Section 125/Cafeteria/Premium Only Plan In Place?			Yes No
* Voluntary Benefits (employee paid) In Place?			Yes No
	If yes, Current Carrier(s):
Employer Contribution Percentage for Employees?			---- Select ---- 50% 60% 70% 80% 90% 100%
Employer Contribution Percentage for Employee Dependants?			---- Select ---- 0% 50% 60% 70% 80% 90% 100%
Interested in fully or partially self funded plans?			Yes No
Additional Group Comments, Questions?