Nevada Small Group Proposal RequestCreated OnMay 31, 2020Last Updated OnJune 2, 2020 You are here: Resources Quote Forms Nevada Small Group Proposal Request < BackPlease enable JavaScript in your browser to complete this form.Business/Group InformationCOMPANY NAME *YOUR EMAIL ADDRESS *EmailConfirm EmailYou will receive a copy of this form here. Be sure to check your junk/spam folder.ADDRESS *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNATURE OF BUSINESS *CORPORATE STRUCTURE *Sole ProprietorCorporationLLCParternshipOtherCORPORATE STRUCTURE OTHER *BUSINESS START UP DATE *DO YOU HAVE MORE THAN ONE LOCATION? *YesNoNUMBER 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 *AllManagementHourlySalaryNon-UnionCURRENT RENEWAL DATE *DESIRED EFFECTIVE DATE *Current CoverageWHAT IS YOUR CURRENT COVERAGE (check all that apply)MedicalDentalVisionLifeMEDICAL CARRIER *HOW LONG HAVE YOU BEEN WITH THEM? *PLAN TYPE (check all that apply)HMOPPOEPOHSAPOSARE YOU WITH A PEO? *YesNoDENTAL 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)DHMOPPO Annual MaxIS THE PLAN *VoluntaryEmployer PaidVISION CARRIER *HOW LONG HAVE YOU BEEN WITH THEM? *IS THE PLAN *VoluntaryEmployer PaidLIFE 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 DisabilityShort Term DisabilityCancerCritical IllnessGap CoverageAccident CoverageLifeWHICH PLANS WOULD YOU LIKE A QUOTE FOR (check all that apply)?MedicalDentalVisionLifeWorksite BenefitsMEDICAL PLAN TYPE (check all that apply) *AllHMOPPOHSAPOSWHAT IS YOUR MAIN EMPLOYEE BENEFIT CONCERN? *PricingBenefitsServiceOtherOTHER CONCERN *PLEASE EXPLAIN *CommentSubmit
