GROUP NAME:
CITY: STATE: ZIP:
COUNTY: PHONE: FAX:
E-MAIL:
PRESENT HEALTH CARRIER:
NATURE OF BUSINESS:
ANY PRE-EXISTING CONDITIONS: YES NO
OR PREGNANCIES: YES NO

PLAN SPECIFICATIONS:
MARK IF REQUIRED

I. HEALTH INSURANCE
PPO OPTION RX COPAY OFFICE COPAY
DEDUCTIBLE: $100 $250 $500 COINS: $2500 $5000

II. DENTAL
CURRENTLY IN FORCE DEDUCTIBLE:
WAIVED CLASS 1
CLASS 1 CLASS 2 CLASS 3
ANNUAL MAXIMUM ORTHODONTICS

LIFETIME MAXIMUM

III. GROUP LIFE
FLAT AMOUNT
SCHEDULED AMOUNT X SALARY TO A MAXIMUM
OCCUPATIONAL CLASS AMOUNT: a b c

IV. DEPENDENT LIFE
SPOUSE: YES NO CHILD(REN)

V. SHORT TERM DISABILITY
BENEFIT DESIGN DATE:
FLAT AMOUNT $
PERCENTAGE % TO A $ WEEKLEY MAXIMUM

VI. LONG TERM DISABILITY
ELIMINATION PERIOD DAYS BENEFIT PERIOD
FLAT AMOUNT $
PERCENTAGE % TO A $ MONTHLY MAXIMUM

NUMBER OF EMPLOYEES:

NOTES: