GROUP INSURANCE FORM
Employer's Name
Address Line 1
Address Line 2
City, State and Zip
 State Zip
Phone
 e-mail
I am interested in Group Health
Desired Effective Date
Amount ($) or Percent (%) that Employer Contributes to Employee Portion of the Premium:
Amount ($) or Percent (%) that Employer Contributes to Dependent Portion of the Premium:
Name of current carrier
How long with current carrier
Current Plan Design:
 PPO
HMO
Both PPO & HMO
In-network deductible:
Out-of-network deductible:
In-network coinsurance %:
Out-of-network coinsurance %:
In-network out-of-pocket maximum amount:
Out-of-network out-of-pocket maximum amount:
In-network office visit copay amount:
Prescription drug (Rx) copay amounts:
 Generic
Preferred Brand Name
Non Preferred Brand Name
If Rx has a separate deductible, what is that amount?
I am interested in Dental Coverage
Deductable
Annual Maxiumum
Coinsurance Preventative
in network out of network
Coinsurance Basic
in network out of network
Coinsurance Marjor
in network out of network
Is orthodontia covered?
 Yes, with lifetime maxiumu of
No
How are Periodontics and Endiodontics coverd?
 Basic
Major
Employer Contribution
Desired Effective Date
I am interested in Long Term Disability
Elimination Period
"Own Occupation" Period
Benefit Period
Benefit Percentage
Maximum Monthly Benefit
Desired Effective Date
Employer Contribution
I am interested in Short Term Disability
Elimination Period
 Accident Sickness
Benefit Period
Benefit Percentage
Maximum Monthly Benefit
Desired Effective Date
Employer Contribution
I am interested in Basic Life and Accidential Death & Dismemberment
Type of Plan
 Flat Amount:
"Times Earnings" Formula (e.g. 1xSalary)
Desired Effective Date
All Lines of Coverage

Please provide current (and renewal, if possible) rates.

Please include any comments if necessary:
Custom employee benefit programs designed to match your organization's philosophy, objectives and budget.