Employee Benefits Quote Request

Davis Associates Employee Benefits Quote Request

Company Name:

Address:

City: State: Zip:

County: Phone:

Please attach a copy of your current census or fill out below

Employee Name Gender DOB Single 2 Adults Parent/Child Family Current Coverage Information

Please attach a copy of your current Benefit Summary or fill out below

Current Carrier:

Plan Type: PPO OA/DA/NG POS HMO

HMO – OA/NG HSA HRA

Out-of-Network Deductible: $

In-Network Deductible: $

Out-of-Network Co-Insurance: 90/10 80/20 70/30 60/40 50/50

In-Network Co-Insurance: 90/10 80/20 70/30 60/40 50/50

Office Visit Co-Pay: $ Hospital Co-Pay $

ER Co-Pay: $ Outpatient Co-Pay $

Prescription Card $

Other Benefits Requested: Dental Vision LTD STD

Group Term Insurance AD&D

 50+ group requirements: Current census with zip code, benefit summary, current bill, current renewal and contribution schedule.

 100+ group requirements: Please submit all the above plus current claims history