Forms for Insurance Brokers
Census
2 - 50
This spreadsheet lists the Employee Name, Gender, Date of Birth, Marital Status
and Home Zip Codes. This information is required when quoting companies with
over 50 employees, out of New York State companies and companies with out of
state Employees.
Census
50+
This spreadsheet also lists the Employee Name, Gender, Date of Birth,
Marital Status and Home Zip Codes. This form is a continuation for
companies who have over 50+ employees, companies out of New York
State companies and companies with out of state Employees.
Census
Life and Disability
This spreadsheet lists the Employee Name, Gender, Date of Birth,
Marital Status and Home Zip Codes. This information is required when
quoting Life and Disability Insurance.
Detailed
Group Referral - Current Information
This form details a clientís current group health insurance
information. With this information, we are able research the market
for competitive plans and rates.
Detailed
Group Referral - Plan Interested In
This form details the plan design the clients are interested in.
With this information, we are able to custom-tailor a plan that meets
our clientsí group insurance requests.
Group
Referral Form
This is the standard Group Referral Form that we use to gather information
about our clients, their current plans and the plans that they are
looking to purchase. This form is simple and does not go into as
much detail as the Detailed Group Referral forms do. Please put your
name, email address and phone number on the top of the form. Fill
out as much information as you can. We require the company name,
zip code and census in order to calculate accurate quotes.
Multi
State & Subsidiary Addresses
Many clients we come in contact with have multi state locations as
in having a New York main office and offices in other states or subsidiaries
in various locations that they would like to cover under their Group
Insurance plan. In this case, we ask that you have your client complete
this form so we may quote the necessary companies. If your client
has employees or companies outside of New York State, please ask
them to complete a Census form along with this one for their main
location, its other offices or subsidiaries.
Physician
Survey Report
This spreadsheet asks that your client complete the Physicianís
Name, Phone Number, City State and Zip Code and Specialty. This information
is requested in order to ensure that your clientsí doctors
and hospitals will be covered within the health insurance plans we
quote for them.
Prescriptions
This worksheet asks that you complete the name of your prescription
and what it is used to treat. This information is requested in
order to ensure that your clientsí prescriptions will be
covered within the health insurance plans we quote for them. We
will then complete the last column and inform your clients as to
what tier structure their prescriptions will be covered under and
at what cost.
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