RFP- Group & Individual- updated 04-14-14

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Short Term Disability

How can we help you?

Please tell us what type of quote you need: Individual Group/Small Employer Direct Pay

Tell Us About the Business

What type of quote are you requesting?* Group only Small Employer Direct Pay only Both

Company Contact Information

Business Name*

Address 1*

Address 2

City*

State*

Zip*

Main Phone*

Fax Number

Website*

Primary Contact Person

Name*

Position or Title*

Phone Number*

Extension

Email Address*

General Company Information

How Many Employees?

Full-Time*

Part-Time*

1099 Contractors*

Will 1099's be offered benefits?* Yes No

Industry*

Business Info

Year Established*

Deduction Mode (select all)* Weekly
Bi-Weekly
Semi-monthly
Monthly

Billing Mode (select all)* Payroll Deduction
Direct Pay

Number of locations*

List all states with locations*

Proposal Request Information

Select Products to Include in the Proposal* Fully Insured
Self Insured
MEC Plan
Limited Medical
Dental
Vision
Term Life
Universal Life
Whole Life
Accident
Indemnity Cancer
Lump Sum Cancer
Critical Illness
Hybrid Supplemental
GAP
Short Term Disability
Long Term Disability
Long Term Care
Telemedicine
Medicare
Annuities
Final Expense

Proposed Enrollment Start Date*

Proposed Effective Date*

Will the company contribute to the benefits?* Yes No

Please provide details about the company's contribution.

Is this a carrier takeover?* Yes No

Please list carrier(s) and plan(s) to be taken over

Identify specific carriers to propose, or leave blank

Identify specific carriers to exclude, or leave blank

Select any value-added services you would like included* Defined Contribution Plan Documents
Online enrollment
HRM
Single Point Billing
Auto Appointment Scheduler
Virtual Benefits Corner (online product comparison)
Client-Specific Website
None

Upload Employee Census File*

Are there any multilingual needs?* Yes No

Please list languages(s) needed

Current Company Benefits

Currently have Section 125* Yes No

Type of 125 Plan

Name of current Section 125 provider

Plan Year Start Date

Date You Want to Receive the Proposal (minimum of 1 week)*

Please provide additional details about the current benefits

Upload Current Benefits Plan Designs

I would like quotes for

Whole Life* Yes No

Term Life* Yes No

Universal Life* Yes No

Medicare* Yes No

Annuities* Yes No

Final Expense* Yes No

Short-term Disability* Yes No

GAP* Yes No

Medical off exchange* Yes No

Do you have children? Yes No

Dental* Yes No

Vision* Yes No

Telemedicine* Yes No

Cancer* Yes No

Tell Us About the Individual

Primary Applicant

Gender* Female Male

Date of Birth*

Height (ex. 5' 5")

Weight

Use tobacco products?* Yes No

Marital Status*

Number of Children*

Projected Annual Income*

Please provide details about current benefits

Upload Current Benefits Info

Spouse / Partner Information

Gender Female Male

Date of Birth

Height (ex. 5' 5")

Weight

Use tobacco products? Yes No

Projected Annual Income

Information About Your Child(ren)

Child #1 Information

Gender Female Male

Date of Birth

Child #2 Information

Gender Female Male

Date of Birth

Child #3 Information

Gender Female Male

Date of Birth

Child #4 Information

Gender Female Male

Date of Birth

Child #5 Information

Gender Female Male

Date of Birth

Child #6 Information

Gender Female Male

Date of Birth

Child #7 Information

Gender Female Male

Date of Birth

Child #8 Information

Gender Female Male

Date of Birth

Child #9 Information

Gender Female Male

Date of Birth

Please provide the gender and DOB's of each of your children in the box.

Contact Information

First Name*

Last Name*

Primary Phone*

Alternate Number*

Email*

Address 1*

Address 2

City*

State*

Zip*

Please enter what you see in the box.

Thank you for your submission.