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2021-06-14T12:00:17-04:00
Agency Information
Agent Name
(Required)
Agency Name
Email
(Required)
Phone
Group Information
Name
(Required)
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Effective Date
(Required)
MM slash DD slash YYYY
Is the group a takeover or startup company?
(Required)
No
Takeover
Startup
Disability (Short Term/Long Term)
Employer contribution amount
Benefit summary to quote
Yes
No
Census including
Gender
Date of birth
Job title
Salary
Job class, if applicable
Elections/Waivers
Upload Census for Disability
Accepted file types: xlsx, xls, csv, Max. file size: 32 MB.
Life Insurance
Employer contribution amount
Benefit summary to quote
Yes
No
Census including
Gender
Date of birth
Salary
Job class, if applicable
Elections/Waivers (Contributory)
Employee/spouse elections and life
volumes if quoting voluntary life
Upload Census for Life Insurance
Accepted file types: xlsx, xls, csv, Max. file size: 32 MB.
Dental Insurance
Employer contribution amount
Benefit summary to quote
Yes
No
Census including
Gender
Date of birth
Job class, if applicable
Family Status - Elections/Waivers
Upload Census for Dental
Accepted file types: xlsx, xls, csv, Max. file size: 32 MB.
Vision Insurance
Employer contribution amount
Benefit summary to quote
Yes
No
Census including
Gender
Date of birth
Job class, if applicable
Family Status - Elections/Waivers
Upload Census for Vision
Accepted file types: xlsx, xls, csv, Max. file size: 32 MB.
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