Thank you for considering Insurance Brokerage Service for your company's group insurance. We represent many companies offering group coverages and will be happy to search them to find the best rate for you. In our on-line Quote Request Form that follows you can enter your group's census of up to nine employees. If you have ten or more employees you can fill out that part of the form specifying the coverages you want, then FAX us your census separately (our FAX number is 615-383-5174) or you can put nine employees on this form, send it, then add other employees and send it again until you have sent the entire census.
Please answer all questions on the form carefully. If you have a specific date by which you want your quote, please specify that in the message area at the end of the form. We can quote several companies from our office and give you 24-hour turnaround if needed. If you have more time (it never takes more than five working days to receive all quotes) we can increase the number of companies we ask to quote on your plan.
We will furnish you a spreadsheet comparison of all of the quotes we receive, plus a detailed comparison of up to four of the plans we recommend. If you need a 24-hour quote, we will provide you with a summary of all quotes we receive instead of the more detailed comparison just mentioned. We look forward to receiving your request and furnishing you with our quotes.
Your Name:Comp Name: Address: City: State: Zip Code: Phone: FAX: E-Mail: County:Type Business:
Do you presently have Group Medical Insurance? No Yes
With what insurance company are you with (we don't want to contact your present carrier)?
And what is your present monthly premium?
Is ANY employee or covered dependent currently pregnant, hospitalized or out of work due to an illness or injury? No Yes
If your answer was "yes", please provide details now.
Has ANY employee or covered dependent EVER had cancer, diabetes, a heart disorder or any other serious illness or injury? No Yes
In the last 12 MONTHS has ANY employee or covered dependent received treatment for ANY chronic or serious medical condition? No Yes
Is it OK to quote a PPO plan? No Yes
Is it OK to quote an HMO plan? No Yes
What Deductible do you wish quoted? $250 $500 $ 1,000 $ 2,500 $ 5,000 $ 10,000 $20,000
What Co-Insurance Percentage do you wish quoted? NOTE: 100% plan only available with deductibles of $2,500 and higher
50% 60% 70% 80% 90% 100%
What Stop-Loss do you wish quoted? $500 $1,000 $2,500 $5,000
Do you want a Supplemental Accident Benefit quoted? No Yes
Do you want a Maternity Benefit quoted? No Yes
Do you want a Wellness Benefit quoted for you? No Yes
Do you want Dental Insurance quoted for you? No Yes
Quote Short-Term Disability? Don't Quote 1/8/13 8/8/13 14/14/13 1/8/26 8/8/26 14/14/26
If quoting Short-Term Disability, what weekly benefits should be quoted? N/A 50% of Salary 2/3 of Salary $100/employee $150/employee $200/employee $250/employee $300/employee
Quote Long-Term Disability? Don't Quote 30 day EP 60 day EP 90 day EP 180 day EP 365 day EP
If quoting Long-Term Disability, what benefit period should be quoted? N/A 1 year 2 years 5 years To Age 65
If quoting Long-Term Disability, what monthly benefits should be quoted? N/A 50% of Salary 2/3 of Salary
Annual Life Spouse # of Employee Age Sex Family Status Salary Insurance Age Children
If you have any questions or would like to provide us with any other information, please enter it in the space below, then send the entire form to us by clicking on the SEND button.
