Group Information

Current Insurance Company:

How Long?

Name of Your Company:

Address:

Phone Number:

President:

Contact person:

Number of employees:

Anniversary Date for Medical Insurance:

Anniversary Date for Business Insurance:

Please indicate the current insurance carriers for the following coverages:

MEDICAL INSURANCE

CURRENT RATES:

Single:

Emp + Sp:

Emp+Ch:

Family:

WORKERS COMPENSATION

DISABILITY

CURRENT RATES:

LONG:

SHORT:

Voluntary:

LIFE INSURANCE

CURRENT RATES:

DENTAL

CURRENT RATES:

Single:

Emp + Sp:

Emp+Ch:

Family:

401K

CURRENT ASSETS:

Do you have a broker/consultant?

Are you happy with their services? Yes or No pulldown box

Relationship:

How long have you worked with them?

BUSINESS LIABILITY

Please inform us of any questions, problems, or concerns with current inforce insurance coverages.