PROPOSAL REQUEST FORM

Group Name:
Agent Name:
Agency Name:
Address:
City:
State:
County:
Zip Code:
Phone:
Fax:
Industry:
E-mail:
     
BENEFIT SELECTION
 
Deductible Option   Copay Option
$250
$500
$1,000
$2,500		  

100/70
100/50
90/80
90/70
80/60

     
Prescription Drug Card   Supplemental Accident Benefit
$10/25/50
$10/20/35
   $500
None
     
Dental   Short Term Disability
$
Deductible
Schedule
$
Calendar Year Max
 
$
Amount per Week
Schedule
     
Life Insurance ($15,000 included): $ additional
Dependent Life
24 Hour Coverage
Group Currently has Worker's Compensation
   
Group Census
EE#
Employee Name
DOB
mm/dd/yy
Gender
Family Status
# of Children
Annual Salary
Job Title/ Description
1
2
3
4
5
6
7
8
9
10
11
12