Group Retiree Medical/Rx Request For Quote

Assistance and advice from over 100 licensed health & life insurance agents and representatives.

Please fill out our safe, secure and easy online application.

* Indicates a required field.

General Information

*Name of Sponsoring Entity:

*Situs State:

*Contact Person:

*Phone Number:

 () -

*Address:

*City:

*State:

*Zip:

*Email:

*Nature of Business:

List all subsidiaries, affiliated companies, and addresses that are eligible:

Employer Contribution will be (complete one or all sections):

Retiree %

$ Dollar Amount

Spouse%

$ Dollar Amount

If Contribution is variable, please explain:
 
Current Coverage

*Current Plan of Benefits is:

 Self-Funded
Insured

*Please provide number of persons covered and current rates:
 

Retirees Over Age 65   Rate

$
Retiree + Spouse Over Age 65   Rate $
Retirees Under Age 64   Rate $
Retiree + Spouse Under Age 65   Rate $
 
Plan Request (Select one or more)

Comprehensive Retiree Medical Plan Options
(Note: Complete plan brochures are available on the Retiree Medical page of our website.)

Retiree Med Choice
Retiree Med Plus
Retiree Med Preferred
Please provide options based on your requirements in the following box

Special request for Retiree medical Plan Design:

Medicare Advantage Plans
(HMO, PPO, Fee-for-Service)

Medicare Advantage With Rx
Medicare Advantage No Rx

Medicare Part D Prescription Drug Plan Alternatives

Provide Various Options (40 various options available)

Group Plan Options

Dental
Vision
 
Census Information
(Note: If more than one person, please upload a file with all census information)

Name:

Gender:

 Male  Female

Date of Birth:

 //

Zip:

Upload:
 
Administration

*Desired Effective Date:

 //

List Bill Employer
Direct Bill Policyholder
Other
Please explain below
 
Producer Information (if applicable)

Name of Consultant/Broker:

Address:

City:

State:

Zip:

Submitted By:

Phone Number:

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