Group Insurance Proposal Request

Diversified Insurance Brokers, Inc.

Please complete the following Agent and Applicant information.  If you are not currently a registered Agent with Diversified Insurance Brokers, you will need to complete the Agent Registration form.  

 

Please provide the following contact  information:

We request the contact information here to ensure prompt and accurate response to your needs.

 

Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone (Required)  
 FAX
 E-mail (Required)   

Please provide the following information on the company:

Company  Name
How Long in Business
Street Address
Address (cont.)
County
City
State/Province
Zip/Postal Code

Describe nature of 

Company's Business
Number of Eligible Employees
 Number of Employees to Enroll

If all employees not enrolling, 

explain why some are not enrolling
Does Company have Coverage Now? Yes No
If yes, with whom
Current premium, if known
Renewal rate, if known

Any claims in past 2 years in excess 

of $3,000?

 Yes No

If claims in excess of $3,000 exists, 

please enter the date of the claim, 

the amount, the nature of the claim

 

Is the person still being treated?

 

If yes, explain how

Yes No

Number of employees related by blood
Number of employees related by marriage
   

Please indicate the type of plan desired:

Deductible amount desired
Life Insurance amount desired
Co-insurance (80/2500, 80/5000, etc)
Pre-certification required Yes No
Options:  Maternity Yes No
Options:  Supplemental Accident Yes No
Options:  Dental Yes No
Options:  Prescription Card Yes No
Options:  Disability Income Yes No
               If yes, disability amount desired

Other information for this quote:

Please describe any health conditions currently being treated.
Can the group go through underwriting? Yes No
Any current employees pregnant or disabled? Yes No
What is the proposed effective date for the policy?

If the company has 20+ people who will be on this plan, then:

How many currently on COBRA

For those on COBRA, explain reason, including if health related

 

 

 

Group Census Information

Diversified will need a census for each insurance type to be offered. (ie Dental, Medical, LIfe, Disability)

Indicate how you plan to provide this census information.

You can FAX to 770 662-0516 or email to 

Rick@Diversifiedins.com

 

 

 

Via FAX or    Via EMAIL Attachment

Please enter any other comments or questions for the quote.


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Diversified Insurance Brokers Quotation Policy  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.  A Diversified representative can complete a personalized quote for you over the phone.
Copyright ©2001 Diversified Insurance Brokers. All rights reserved.     Rev: November 17, 2002

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