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Nevada Small Group Proposal Request
Created On
May 31, 2020
Last Updated On
June 2, 2020
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Business/Group Information
COMPANY NAME
*
YOUR EMAIL ADDRESS
*
Email
Confirm Email
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ADDRESS
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
*
Comment
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