GROUP NAME__________________________________________________________________
CITY_______________________ STATE_____ ZIP______ COUNTY______________________
PRESENT HEALTH CARRIER______________________________________________________
NATURE OF BUSINESS___________________________________________________________
ANY PRE-EXISTING CONDITIONS OR PREGNANCIES________________________________

PLAN SPECIFICATIONS:
MARK "X" IF REQUIRED OR "O" IF OPTIONAL

I. HEALTH INSURANCE
PPO OPTION___ RX COPAY___ OFFICE COPAY___
DEDUCTIBLE: $100___ $250___ $500___ COINS: $2500___$5000___

II. DENTAL
CURRENTLY IN FORCE___ DEDUCTIBLE___ WAIVED CLASS1__
CLASS 1___ CLASS 2___ CLASS 3___
ANNUAL MAXIMUM___ORTHODONTICS___ LIFETIME MAXIMUM___

III. GROUP LIFE
___FLAT AMOUNT___
___SCHEDULED AMOUNT___ X SALARY TO A MAXIMUM___
___OCCUPATIONAL CLASS AMOUNT: a___ b___ c___

IV. DEPENDENT LIFE
SPOUSE___ CHILD(REN)

V. SHORT TERM DISABILITY
BENEFIT DESIGN DATE ___/___/___
___FLAT AMOUNT $___
___PERCENTAGE___% TO A $___WEEKLEY MAXIMUM

VI. LONG TERM DISABILITY
ELIMINATION PERIOD___DAYS BENEFIT PERIOD___
___FLAT AMOUNT $___
___PERCENTAGE___% TO A $___MONTHLY MAXIMUM

#	EMPLOYEE	D.O.B	SEX	MARRIED	CHILDREN	INCOME	TITLE
1
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3
4
5
6
7
8
9
10
11
12
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16
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20
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22
23
24

 

NOTES:

 

 

 

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