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Coverage Requested |
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Medical: |
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Plan Type:
PPO HMO
Comprehensive |
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Deductible: $0
$250 $500
$1,000 |
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Co-Insurance (In-Network / Out-of-Network): 100/70
90/70 90/60
80/70 80/60
70/60 |
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Office Visit Co-Pay: $10
$15 $20
$25 $30 |
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Drug Card:
Yes No |
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Current Rates: |
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Group Life Insurance:
$10,000 $15,000
$20,000 1x
Salary |
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Dental Insurance: |
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Deductible:
$0 $25
$50 $75 |
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Waive Deductible on Preventive: Yes
No |
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Preventive Covered at: 100%
80% 50% |
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Basic Covered at: 80%
50% |
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Major Covered at:
50% |
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Annual Maximum: $1000
$1500 |
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Orthodontics (Available for 10+ Groups): Yes
No |
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Current Rates: |
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Long-Term Disability |
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Elimination Period: 30
days 60
days 90
days 180
days |
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Monthly Benefit: 60%
of Salary 70%
of Salary |
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Maximum Monthly Benefit: $2500
$5000
$7500
$10,000 |
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Length of Benefit: 2
year own occupation 3
year own occupation |
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Current Rates: |
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Short-Term Disability |
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Elimination Period: 7
days 15
days 30
days |
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Weekly Benefit: 60%
of Salary 70%
of Salary |
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Maximum Weekly Benefit: $250
$500
$750
$1,000 |
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Length of Benefit: 13
weeks 26
weeks |
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Current Rates: |
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Employee Census |
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** EE = single, ES = ee+spouse, EC = ee+child(ren), FF =
family |
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Date of Birth:Sex:M
F Status: |
Date of
Birth:Sex:M
F Status: |
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Date of Birth:Sex:M
F Status:
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Please include all eligible employees, even if they are
waiving coverage. |
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Company Information |
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Company Name: |
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Contact Name:
E-Mail Address: |
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City: State:
Zip: |
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Phone Number: |
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Fax Number: |
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Type of Business: |