<p> Davis Associates Employee Benefits Quote Request</p><p>Company Name: </p><p>Address: </p><p>City: State: Zip: </p><p>County: Phone: </p><p>Please attach a copy of your current census or fill out below</p><p>Employee Name Gender DOB Single 2 Adults Parent/Child Family Current Coverage Information</p><p>Please attach a copy of your current Benefit Summary or fill out below</p><p>Current Carrier: </p><p>Plan Type: PPO OA/DA/NG POS HMO</p><p>HMO – OA/NG HSA HRA</p><p>Out-of-Network Deductible: $ </p><p>In-Network Deductible: $ </p><p>Out-of-Network Co-Insurance: 90/10 80/20 70/30 60/40 50/50</p><p>In-Network Co-Insurance: 90/10 80/20 70/30 60/40 50/50</p><p>Office Visit Co-Pay: $ Hospital Co-Pay $ </p><p>ER Co-Pay: $ Outpatient Co-Pay $ </p><p>Prescription Card $ </p><p>Other Benefits Requested: Dental Vision LTD STD</p><p>Group Term Insurance AD&D</p><p> 50+ group requirements: Current census with zip code, benefit summary, current bill, current renewal and contribution schedule. </p><p> 100+ group requirements: Please submit all the above plus current claims history</p>