Home Contact Us FAQ Industry Links Site Map

Group Life Group Health Individual Health Hospital Indemnity Short Term Medical Metal Gap Individual Drug Individual Dental Long Term Care Impaired Risk Travel Medical Disability Simplified Life Graded Life For Agents

 

Preliminary Group Life & AD&D Inquiry - Not an application for insurance
 

 

Background

P Submitted By  Date Needed: 
P Agency
P Group Name
P City    State
P    
P SIC Code   # of Lives 
P Options Life  Dep    VTL    STD    LTD VOLDIS  Effective Date
 

Basic Life, AD&D and Dependent Life

P

Participation:

  Non-Contributory   Contributory     Contributory Percent:
  Dependent AD&D

1=Yes/Seat Belt Rider
2=Yes/NO Seat Belt Rider
3=No

Dependent Life 2-Tier 3-Tier
   Plan 1      Spouse   Child  
   Plan 2      Spouse   Child  
   Plan 3      Spouse   Child  
   Plan 4      Spouse   Child  
P Reduction Schedule ADEA        Special 
P Other Benefits ALB  Suicide Exclusion  Seat Belt Benefit
P Waiver Age    Waiting Period    Termination Age 
  Descriptions

For Basic Life, AD&D, Dependent Life

Multiple of Salary or Flat Amount

  Class 1 or Quote 1 Multiple    Flat Amount
  Class 2 or Quote 2 Multiple    Flat Amount
  Class 3 or Quote 3 Multiple    Flat Amount
  Class 4 or Quote 4 Multiple    Flat Amount
 

Long Term Disability

  Participation  90-100%   80-89%  75-79%  Non-contributory 
    Item Class 1 or Quote 1 Class 2 or Quote 2 Class 3 or Quote 3
    Benefit%
    Benefit Duration

    Benefit Maximum
    Elimination Period
    Integration

    Pre Exam

    Yes    No

    Yes    No

    Yes    No

    MMB
    Def of Disability
    Class Description Class 1 
    Class 2 
    Class 3 
 

Company Census Information     as of

 
   Employee Name Gender DOB Salary Job Title/Occupation Life Class LTD Class STD Class
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
 

Agent Information

P Agent Name   
P Agency Name
P Address
P City
P State
P Phone
P Email
P Fax number
  Other Comments

Please be specific with above information and include phone numbers. 
It will expedite processing


Robert D. Fink and Associates  After filling out the necessary information on this form you will receive a quote via phone or email and then have the option of applying for the actual overage. There is no commitment for filling out the information on this form and receiving a quote. 

Last Updated:
07/24/2004