IC - New Group Quote Request

1
Group Legal Name* This field is required.
2
Home Office Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Contact Person and position with the company* This field is required.
Contact First Name
Contact Last Name
Contact Position
4
Phone Number* This field is required.
Area Code
Phone Number
5
E-mail* This field is required.
6
Number of years in Business
7
Owner or CEO
8
EIN/TIN* This field is required.
9
SIC/NAICS* This field is required.
10
Special Requests
11
Number Of Full Time Employees
12
Number Of Part Time Employees
13
Number Of Full Time Equivalency Employees
14
Do you currently have group coverage in place?
YESNO
15
Carrier Name* This field is required.
16
Renewal Date* This field is required.
Date
Year
Month
Day
17
Number of Year with This Carrier
18
Open Enrollment Start Date* This field is required.
Date
Year
Month
Day
19
Open Enrollment End Date* This field is required.
Date
Year
Month
Day
20
New Employee Waiting Period
0 Days
30 Days
60 Days
90 Days
21
Current Tier RatePlease enter your premium rate in dollars.
Employee Only
Employee Spouse
Employee Child
Employee Family
22
Employer Contribution Percentage or Dollar amount?Please enter your premium rate in dollars.
Employee Only
Employee Dependants
23
Do you have multiple office locations?
YESNO
24
Are all locations on a combined payroll system?
YESNO
25
Do you have multiple companies under combined ownership?This question is only asked due to COBRA Eligibility and ACA ALE considerations.
YESNO
26
Do You Offer Other Benefits Programs?
HSA
HRA
FSA
Dental
Life
Vision
Disability
Accident/Gap
27
What is your company’s SIC code?
28
Please download and fill out the Census Spreadsheet available here:
Census Spreadsheet Download
(You will upload the completed Census in the next section)
29
Census Spreadsheet UploadSupported formats: Excel, .CSV
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
Please download and fill out the Census Dependents Spreadsheet available here:Census Spreadsheet Download(If you want to quote your employees without dependents you may skip this form.)
Todo
In Progress
Done
31
Dependant Census Spreadsheet Upload (Please skip if not needed)Supported formats: Excel, .CSV
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
32
Please verify that you are human* This field is required.
Should be Empty: