800-211-7819 (Toll-Free)
234-1419 (Local Area)
PROPOSAL REQUESTS
HEALTH/MEDICAL, DENTAL, AND VISION PROPOSAL REQUESTS
PLEASE PROVIDE:
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Gender for each employee and dependent for Health/Medical coverage. Gender for employee only for Dental and/or Vision coverage.
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Date Of Birth for each employee and dependent for Health/Medical coverage. Date Of Birth for employee only for Dental and/or Vision.
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Zip Code for each employee and dependent for Health/Medical coverage. Zip Code for employee only for Dental and/or Vision coverage.
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Employee Coverage Status--Single, Employee/Spouse, Employee/Child, Employee/Children, or Family.
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Tobacco Usage--for Health/Medical coverage only--for each employee and dependent indicate if there has been any tobacco usage within the last six months.
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Present Carrier and benefits or desired benefits.
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COBRA Information: employees on Cobra with their benefits termination date.
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Groups with 50 or more employees--please call us as we may need additional information.
We will meet with you to help you attain this information or you can fax or e-mail it to us. We can also scan or fax you a census form to compile the above information.
LIFE, SHORT TERM DISABILITY, AND LONG
TERM DISABILITY PROPOSAL REQUESTS
PLEASE PROVIDE:
(1) Gender.
(2) Date of Birth.
(3) Occupation.
(4) Income--Annual, Monthly, or Weekly.
(5) Current carrier and benefits or desired benefits.
We will meet with you to help you attain this information or you can fax or e-mail it to us. We can also scan or fax you a census form to compile the above information.