MBS Insurance - Malpractice & Liability Insurance

GROUP HEALTH INSURANCE QUOTATION REQUEST

Company Name or Individual Name:

Office Address:

Phone Number:

Contact Person:

SMALL EMPLOYER REFORM ACCEPTABLE GROUP ASSESSMENT

Does your company file taxes in this state?

YES NO

Did you employ an average of 2-50 persons (including owners and partners), who worked at least 20 hours per week during the preceding calendar year?
YES NO

Are at least 75% of all eligible employees, after waivers for other group coverage, Medicare (Parts A&B), MCHA, Medical Assistance or General Assistance Medical Care applying for health coverage?
YES NO

Is there an employer- employee relationship?
YES NO

Will the employer contribute 50% or more of the employee cost of health coverage?
YES NO

COVERAGE INFORMATION

Medical Short Term Disability Long Term Care Life Insurance Cafeteria Plan

Long Term Disability 401K Vision Dental

CENSUS INFORMATION

Eligible employees (including owners, partners, and officers) are those who work 20 or more hours per week at or from the business premises. Supply information about spouse's age and number of dependents only if you wish to obtain health coverage for them. (Rates for health insurance will NOT take into account the gender of the applicant. This information is however, required to rate life insurance.)

Emp Sex

Date of Birth

# Children

Smoker

Salary

Date Of Hire

M F

YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO

M F
YES NO