Group Benefits Insurance Health Life Employee
Employer Health Benefits - Retirement - Group Life - Disability - Long Term Care
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There are five sections that need to be completed.

You will receive a thorough comparison of group health insurance products in an easy to read outline. You choose which you are most comfortable with and we can begin the application process and implement your group health efficiently.

 

 

1.) Company Informtion

Company Name
Contact Name
Address
City, State, Zip Code
Telephone
E-Mail Address
     

 

2.) Current Health Plan


Name of Carrier

Choose the type of Plan, Deductible and Co-Insurance you have currently.

Type of Plan
Deductible
Co-Insurance
Traditional $0 100/0
PPO $250 90/10
POS $500 80/20
HMO $1,000 50/50
What percentage of the premium does the employee pay? %

 

 

3.) Employee Information

 
Employee Name
Date of Birth
Spouse
No is default
Number of
Children
Date of Hire
1
Yes
2
Yes
3
Yes
4
Yes
5
Yes
6
Yes
7
Yes
8
Yes
9
Yes
10
Yes
11
Yes
12
Yes
13
Yes
14
Yes
15
Yes
16
Yes
17
Yes
18
Yes
19
Yes
20
Yes
21
Yes
22
Yes
23
Yes
24
Yes
25
Yes

 

 

4.) COBRA

Please list any employees under COBRA

 
Emplyee Name
Date of Birth
Spouse
No is default
Number of
Children
Date of Termination
1
Yes
2
Yes
3
Yes
4
Yes
5
Yes

 

 

5.) Major Health Conditions

List any major health conditions your employees
have or have had in the past five years.

 
Home | Health Benefits | Retirement Benefits | Long Term Care | Life Insurance | Key Employee | Contact Us