| Amount of Group Life Insurance |
|
OPTIONAL
PLAN BENEFITS:
Offline
Carriers Requested:
|
| Medical
Plan Type |
|
Indemnity
PPO
HMO
POS
MSA |
| |
|
Deductible $
Coinsurance $
Copay $
|
| |
|
Dental
STD
LTD
Vision |
| |
|
Life/AD&D $
Maternity $
Supp.Acc. $
|
QUALIFYING QUESTIONS:
|
1)
Coverage In Force?
Yes
No
If Yes: |
| Carrier
Name: |
|
| Plan
Type: |
|
| Premium:
|
|
| Renewal
Month: |
|
2)
Does the employer provide worker's
comp?
Yes
No
|
| 3)
What percentage will employer
contribute towards ee premium?
% |
| 4)
Number of: W2 employees?
1099 employees?
|
| 5)
Budget for employee benefits?
$
|
6)
Deciding factors for new coverage?
|
| 7)
Who will be involved in making
the decision to purchase?
|
| 8)
Currently working with another
broker?
Yes
No |
| 9)
Will make us the broker of record?
Yes
No |
| Role
in Company:
|
| Affiliate:
|
| Opt-In:
|
| HOW
DID YOU HEAR ABOUT US? |
| Individual
|
|
| Agency |
|
| Association |
|
| Company |
|
| Website |
|
Name of referring party:
|
