Group Quote Request

Chad Ellis, Principal

3500 Brooktree Road
Suite 300
Wexford, PA 15090
ph 724.933.8077
fx 724.933.8089

Group Client Information:

Group Name:

Street Address:

Address (cont.):

City:

State:

Zip Code:

County:

Contact Person:

Phone:

Fax:

E-mail Address:

Industry Type:

SIC:

Tax ID:

Answer the Following:

Total number of people on census: Are there any union employees? Yes    No
Does the company offer retirement benefits? Yes    No Has the company filed Chapter 11 in the past year? Yes    No
Has the company been active for 5+ years? Yes   No Amount (%) paid by employer for employee:
Workers Comp Carrier: Amount (%) paid by employer for dependents:
Current Carrier: Requested Effective Date:

Check the Carriers You Would Like to Quote:

Aetna Health America United Concordia
American Medical Security (AMS) Highmark United Health Care
Fortis UPMC Other:

Check Type of Quote Requested:

Group

 

Voluntary

Health Vision Dental LTD STD   Dental Life
Flex 125 401 K HRA HSA Life   STD LTD
Cobra Administration         Other:

Notes:

Employee Census:

Employee Census must be completed and submitted with this request.

Tier = EE - Employee  EC - Employee & Child(ren)  ES - Employee & Spouse  FM - Family  W - Waiver

* Information only needed for quoting wage based life and disability.

Please include all full time employees whether participation or not.

Name

DOB

Gender

Tier

Home Zip

*Job Title

*Mo. Wage

Out of Area Employees:

Employee Census must be completed and submitted with this request.

Tier = EE - Employee  EC - Employee & Child(ren)  ES - Employee & Spouse  FM - Family  W - Waiver

* Information only needed for quoting wage based life and disability.

Please include all full time employees whether participation or not.

Name

DOB

Gender

Tier

Home Zip

Job Title

Mo. Wage

 
 
 

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Copyright 2009 Agora Group, Inc
3500 Brooktree Road, Suite 300, Wexford, PA 15090

Telephone: 724.933.8077