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Nevada Small Group Proposal Request

Created OnMay 31, 2020

Last Updated OnJune 2, 2020

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Nevada Small Group Proposal Request

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Business/Group Information

COMPANY NAME *

YOUR EMAIL ADDRESS *

Email

Confirm Email

You will receive a copy of this form here. Be sure to check your junk/spam folder.

ADDRESS *

Address Line 1

Address Line 2

City

State

Zip Code

NATURE OF BUSINESS *

CORPORATE STRUCTURE *

Sole Proprietor
Corporation
LLC
Parternship
Other

CORPORATE STRUCTURE OTHER *

BUSINESS START UP DATE *

DO YOU HAVE MORE THAN ONE LOCATION? *

Yes
No

NUMBER OF FULL TIME EMPLOYEES *

WHAT IS THE % OF EMPLOYEE PREMIUM TO BE PAID BY EMPLOYER? *

WHAT IS THE % OF DEPENDENT PREMIUM TO BE PAID BY EMPLOYER? *

TYPE OF EMPLOYEES TO BE QUOTED *

All
Management
Hourly
Salary
Non-Union

CURRENT RENEWAL DATE *

DESIRED EFFECTIVE DATE *

Current Coverage

WHAT IS YOUR CURRENT COVERAGE (check all that apply)

Medical
Dental
Vision
Life

MEDICAL CARRIER *

HOW LONG HAVE YOU BEEN WITH THEM? *

PLAN TYPE (check all that apply)

HMO
PPO
EPO
HSA
POS

ARE YOU WITH A PEO? *

Yes
No

DENTAL CARRIER *

HOW LONG HAVE YOU BEEN WITH THEM? *

I consent to having this website store my submitted information so they can respond to my inquiry.

PLAN TYPE (check all that apply)

DHMO
PPO Annual Max

IS THE PLAN *

Voluntary
Employer Paid

VISION CARRIER *

HOW LONG HAVE YOU BEEN WITH THEM? *

IS THE PLAN *

Voluntary
Employer Paid

LIFE CARRIER *

HOW LONG HAVE YOU BEEN WITH THEM? *

AMOUNT OF DEATH BENEFIT *

WORKSITE BENEFITS CARRIER *

LINES OF COVERAGE OFFERED (check all that apply) *

Long Term Disability
Short Term Disability
Cancer
Critical Illness
Gap Coverage
Accident Coverage
Life

WHICH PLANS WOULD YOU LIKE A QUOTE FOR (check all that apply)?

Medical
Dental
Vision
Life
Worksite Benefits

MEDICAL PLAN TYPE (check all that apply) *

All
HMO
PPO
HSA
POS

WHAT IS YOUR MAIN EMPLOYEE BENEFIT CONCERN? *

Pricing
Benefits
Service
Other

OTHER CONCERN *

PLEASE EXPLAIN *

Website

PH: (702) 738-6626
Sheri@MartinInsuranceLV.com
NV Lic. #215275 | NV Lic. #3160782

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Name *

First

Last

Email *

Email

Confirm Email

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Phone *

What would you like to discuss today? *

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Phone

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