PROPOSAL REQUESTS

HEALTH/MEDICAL, DENTAL, AND VISION PROPOSAL REQUESTS 

PLEASE PROVIDE:
 

  1. Gender for each employee and dependent for Health/Medical coverage. Gender for employee only for Dental and/or Vision coverage. 

  2. Date Of Birth for each employee and dependent for Health/Medical coverage. Date Of Birth for employee only for Dental and/or Vision. 

  3. Zip Code for each employee and dependent for Health/Medical coverage. Zip Code for employee only for Dental and/or Vision coverage.

  4. Employee Coverage Status--Single, Employee/Spouse, Employee/Child, Employee/Children, or Family.

  5. 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. 

  6. Present Carrier and benefits or desired benefits.

  7. COBRA Information: employees on Cobra with their benefits termination date.

  8. Groups with 50 or more employees--please call us as we may need additional information.

Family Portrait 5

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.