| Group Insurance Quote |
| Check Type Of Coverage: |
| |
Health
Health Savings Account
Medicare Supplement
Long Term Care
Term Life
Whole Life
Disability
Dental
Cancer/Critical Illness
Medicare Part D Prescription Drug Plans |
To obtain a quote: |
- Complete group information below.
- Life & Health Options will contact you regarding
an employee census.
Census should include the following information
on all full-time employees:
- Date of birth
- Gender (Male/Female)
- Type coverage (EE= Employee only, ES=Employee/Spouse,
EC=Employee/Child(ren), F=Family)
- WOC =waiving due to other coverage
- W = waiving-no coverage
- WP = waiting period
- Questions? Call 225-772-2794, 877-749-8051 toll-free,
or e-mail
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| *Medicare Supplement
Group Quote: As companies look for ways to reduce health
insurance costs, many are scaling back their retiree
benefit plans and offering Medicare Supplements. For
a Medicare Supplement group quote, complete items 1-6
listed below and you will be contacted regarding the
data needed to provide the quote. |
| |
| For a Health, Life, Dental, Disability
or Health Savings Account quote, complete items 1-15. |
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| 1) Contact Person: |
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| 2) Business Name: |
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3)
Street Address:
City, State, Zip: |
,
,
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| 4) Phone number: |
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| 5) Fax: |
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| 6) Email: |
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| 7) Industry Description/Nature of Business: |
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| 8) Total # Full-time Eligible Employees: |
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9) Total # Covered Employees:
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| 10) Effective Date Requested: |
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| 11) Current Carrier/Insurer: |
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| 12) Current Office Visit + Hospital Benefit: |
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13) Current Rates:
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14) Renewal Rates, if available:
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15) Employer Contribution:
(list amount or percentage) |
Employee: |
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| Dependent(s): |
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| Additional comments or questions: |
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| Best time to contact: |
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