376 East Sunland Drive Suite 1 & 2
St. George, UT 84790
435-628-5553 | Contact | Claims Information
 

Group Insurance Quote

General Information

Contact Name *
Contact Email *

Name of Business
Nature of Business
Address
City
State
Zip
Business Phone
Fax

Life and AD&D Coverage

Number of Employees
Number of Employees Eligible
Current Carrier
Renewal Date
Current Rate
Renewal Rate
Flat Amount

Group Health Coverage

Number of Employees
Number of Employees Eligible
Current Plan HMO  POS  PPO  Indemnity
Plan to Quote HMO  POS 
Desired Deductible
Desired Co-Pay
Desired Co-Insurance

Group Dental Coverage

Number of Employees
Number of Employees Eligible
Desired Deductible
Desired Co-Pay
Desired Co-Insurance

Group Disability Coverage

Number of Employees
Number of Employees Eligible
Current Plan STD  LTD
Current Carrier
Renewal Date

Comments

Employee census information including Date of Birth, Sex, Job Title and Earnings will be required. Loss Information will be helpful and may be required on groups over 100 lives.

Please note any other pertinent information or requests for coverages

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Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.