Great Northern Benefits
231.995.9000 p
231.995.0620 f
866.393.0107 toll-free
info@greatnorthernbenefits.com
Request for Coverage Quote - Group
Today's Date:
Requested Effective Date
:
If you are a Sole Proprietor or One Subscriber Group, please see the
Sole Prop/OSG New Business Document Requirements
to find out if your business qualifies for group coverage rates.
If you would like a quote for Life, Disability, Dental, Vision, Long Term Care, or HSA, please
contact us
.
Important!
If your business has between 2 and 50 full-time employees, a census is required prior to quoting for health, vision or dental coverage. The census must contain the following data for each employee: Date of Birth, Gender, Date of Hire, Contract Type (whether the employee will enroll as a one-person, two-person or family). If requesting a quote for life or disability, please add Job Description and Annual Salary in addition to the previous requirements. If any covered employee or retiree is age 65 or older, please also indicate whether they are enrolled in Medicare Part A, B or both.
Business
Name:
DBA:
Address:
City:
State:
Zip:
Nature of Business:
Contact
Name:
Title:
Phone:
Fax:
Email:
Current/Previous Carrier and Plan:
Carrier:
Plan:
Office Visit Copay:
Rx Copay:
Deductible:
Vision:
Dental:
Demographics:
# Single:
# Double:
# Family:
# Family Continuation/
Student Rider:
# Retirees:
