Employer / Group Information
Name of Group
*
How many total employees?
*
Prior Year FTE
*
Eligible Employees?
*
Employees Enrolling?
*
State group is located in?
*
Requested Effective Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Multi-Location Group? (must be in different counties)
*
Yes
No
Common Ownership?
*
Yes
No
Agent Quoting Contact Information
First Name
*
Last Name
*
Company
Phone
*
Format: (000) 000-0000.
Email
*
Are you the current agent?
Yes
No
Are you currently appointed with all carriers quoting?
*
Yes
No
Please be sure to obtain the following
A member-level census in Excel format. Include first name, last name, gender, DOB, resident zip code, and coverage elections (including waivers)
Current Benefit summary for each line quoting
Current and Renewal Rates for each line quoting
Comments
Submit
Should be Empty: