Contact Information
Company Name
*
Requested Effective Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Address
*
Suite No
City
*
State
*
Zip
*
County
Existing Coverage
*
Medical
Dental
Vision
Life & Disability
No Previous Coverage
SIC (
Lookup
)
*
SIC (Lookup)
*
# of Locations
*
# of Eligible Employees
*
FTE/ATNE
*
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of
Medical
Anthem
CareFirst
Kaiser
United HealthCare
Plan Type (check all that apply)
*
HMO
POS
PPO
HRA
HSA
HDHP
Please enter specific plans you would like us to quote:
*
Deductible Amount
*
Dental
CareFirst
Dominion National
Kaiser
Lincoln National
United Concordia
United Healthcare
Please enter the plan name
Preferred Plan Type
Voluntary
Employer-Paid
Voluntary and Employer-Paid
Ortho
Annual Maximums
$1,000
$1,500
$2,000
Vision
CareFirst
Dominion National
Lincoln National
United Healthcare
Please enter the plan name
Preferred Plan Type
*
Voluntary
Employer-Paid
Voluntary and Employer-Paid
Producer Information
Name
*
Are you the current broker?
*
Yes
No
Email
*
Phone
*
Format: (000) 000-0000.
Are you contracted through IMC with all carriers selected above?
*
Yes
No
Comments
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