Insurance Quote Questionnaire

Decision Maker Name*

First Last

Title*

Phone Number*

Email*

Company*

Street Address*

City*

Zip*

Type of Business / SIC Code*

Number of Full Time Employees*

Number of Part Time Employees*

Type of Coverage Interested In (select all that apply)*

Small Group Health, Dental, Vision
Individual / Sole Prop Health, Dental, Vision (under 65 years age)
Medicare
Life
Disability
Workers’ Compensation

Are you an SBAM Member?*

Elite Member
VIP Member
Premium Member
Basic Member
Free Starter Member
I’m not sure. Can you check for me?

If applicable, please let us know your current COBRA vendor:

If applicable, please let us know if you currently offer any of the following:

Health Savings Accounts
Health Reimbursement Arrangement
Flexible Spending Accounts

Please upload your census for employees enrolling including names, gender, DOB, relationship (employee, spouse, dependent), member type and status. If you're requesting a life quote, please include annual salary.*

Max. file size: 50 MB.

Please upload your current plan design with rates, proposed renewal rates, copy of current invoice, and copy of current plan design (Benefits-At-A-Glance or Summary of Benefits and Coverage).

Max. file size: 50 MB.

Deductible

Present Plan – In Network

Coinsurance

Present Plan – In Network

Office Visit Co-Pay

Present Plan – In Network

Specialty Visit Co-Pay

Present Plan – In Network

Urgent Care Co-Pay

Present Plan – In Network

ER Co-Pay

Present Plan – In Network

Rx Coverage

Present Plan – In Network

Out of Pocket Max

Present Plan – In Network

Include Dental Quote

Yes
No

Include Vision Quote

Yes
No

Life and AD&D Benefits Requested

Please choose from the drop down.

Dependent Life

Yes
No

Short Term Disability

Please choose from the drop down.

Long Term Disability

Please choose from the drop down.

Proposed Insurance Effective Date:*

Would you like to see rates in a composite format?*

Yes
No

Please visit www.sbam.org/composite-rating for details.

If you have a current agent that you'd like to continue working with, please list their Name, Email and Phone Number:

Additional Comments:

* Indicates Required Fields

Comments

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