Group Health Proposal Request Form - Please Complete Part A, B, C and then click submit
PART A - COMPANY INFORMATION AND CURRENT BENEFITS
Referring Agent
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How did you hear about us
Today's date and Time
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Day
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AM/PM Option
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Company Name
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Phone
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nature of business
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Street Address
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City
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State
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Zip Code
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Contact e-mail address
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Current Group Health Carrier(s)
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Total Employee's
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# plans offered
Desired Effective date
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Monthly premium for group
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how long with plan
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General description of benefits
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Part B - EMPLOYEE CENSUS - you can fill this section out or e-mail requested information to info@integrated-insurance.com (sending information in excel format is preferred), or click file up load and upload your census
Upload your census here
Name (first OR last), Date of Birth, Gender, Type Coverage (family, spouse, individual etc.), Employee's Zip Code, number of dependants, Hours worked per week, Hourly rate, Tobacco use
PART C - DESIRED COVERAGE - here you need to describe what type of coverage you are looking for
Descibe desired coverage please be sure to indicate maximum deductable and maxium copayment allowances
Are limited office visits acceptable
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Yes
No
I am not sure
Type of coverage
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HMO
PPO
Least $
Dental Coverage
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Yes
No
Not sure
Prescription coverage
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Important
not important
somewhat important
Vision Coverage
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Yes
No
Not Sure
Disabilty Insurance
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Short Term
Long Term
Short & Long
None
add Life insurance
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Yes
No
Not sure
How much Life insurance
Type of retirement opt.
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401K
Profit Sharing
Other
None
any other considerations or comments?
Submit
If you have questions please feel free to call us at 888.823.1342 or e-mail info@integrated-insurance.com
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