Get a quote from Benoit & Associates, Inc.

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Broker Information
Broker Name:

Agency Name:

Agency Address:

City, State, ZIP:

Phone:

Email:

Employer Information
Company Name:

Company Address:

Company City, State, ZIP:

# of Locations:

States:

Nature of Business:

Effective Date (xx/xx/xxxx):

# of Employees:

SIC Code:

Enrollment Information
Proposed method:
One on One
Call Center
Electronic
Group Meetings

Ben-Admin Systems
Voluntary Benefits in a Box:     Yes     No

Name of Platform:

Who is paying fees?

PRODUCTS

Short Term Disability: Yes     No
Eligibility Requested:
Full Time 90 days on job     Part Time     Other

Benefit Period:
90 days     180 days     365 days     2 years

Elimination Period:
0 day accident 7 day illness     7 day accident 7 day illness
14 day accident 14 day illness     30 day accident 30 day illness

Other - please tell us plan design

Take over:     Yes     No
*if yes provide a copy of current plan design & bill when contacted

Benefit Level:
60%     50%     40%

Leave this empty:

PRODUCTS CONTINUED

Long Term Disability: Yes     No
Eligibility Requested:
Full Time 90 days on job     Part Time     Other

Benefit Period:
5 years     To Age 65     SSNRA

Elimination Period:
90 days     180 days     365 days

Other - please tell us plan design

Take over:     Yes     No
*if yes provide a copy of current plan design & bill when contacted

Benefit Level:
60%     66 2/3%

Life Insurance: Yes     No
Term:     Yes     No
Universal Life:     Yes     No

Do you need any special considerations?

Accident Insurance: Yes     No
24 hour coverage:     Yes     No

Critical Illness: Yes     No
Re-Occurance:     Yes     No
Cancer Included:     Yes     No
Wellness:     $50     $100
Pre Taxed:     Yes     No

Cancer Only: Yes     No
Wellness:     $50     $100

Hospital Indemnity: Yes     No

Current Coverages
Does the company have a STD disability plan in force?     Yes     No
Plan design if in force:

Voluntary or Employer paid:     Voluntary     Employer
Replacing Coverage?     Yes     No
Does the company have a LTD disability plan in force?     Yes     No
Plan design if in force:

Does the company have an accident in force?     Yes     No
Does the company have a critical illness in force?     Yes     No
Does the company have a hospital indemnity in force?     Yes     No
Replacing Coverage?     Yes     No

Current STD Carrier:

Current LTD Carrier:

Current Critical Illness Carrier:

Current Cancer Carrier:

Current Accident Carrier:

Current Life Carrier:


Miscellaneous Items
Is employer contributing towards any premiums?     Yes     No
If yes, how much?


Any TPA's involved?     Yes     No
If yes, who?


All premiums payroll deducted?     Yes     No
If no, please explain: