5738 Foremost Drive, SE Grand Rapids, MI  49546
Phone 616-956-0040, 616-949-0490 or 800-530-9221
 

Group Employee Benefits Request for Under 50 Employees

(if over 50 employees, please contact our office direct at 616-949-0490)

This form must be filled out entirely to be considered.

 

Basic Information

Name of Company:                                                                                               Requested Agent:

                  

Address:

City:                                      County:                     State:  Zip:

   

Contact Person:

Phone Number:

Email Address (optional):

Other locations (please list):

Nature of Business:

Number of Active Full-time Employees:

Number Requesting Coverage:

 

Employee Benefits (please check all that apply)
 

Current

Benefits

Requested

Benefits

 
Medical

 
Dental  
Vision  
Group Life  
Short-term Disability  
Long-term Disability  
Pension Plan (401k, etc.)  
Supplemental Insurance  
Flexible Spending Accounts  

 

Current Medical Plan Design

 

Please define plan features below.  Preferably, send a summary of benefits from your insurance company to us by mail, fax or email.

 

Insurance carrier:
Office co-pay:
Deductible amount:
Co-insurance percentage:
Prescription card:
Anniversary/renewal date:

 

Current Renewal Rates

 

  Current Renewal

Employer

Contribution
Single:

Employee/spouse:

Employee/child:
Family:

 

Requested Plan Design

 

Please specify if different from your current plan.

 

Employee & Dependent Medical Information

 

Information about medical conditions among your employees and their dependents helps identify the most competitive insurance solutions.

 

Please list as completely as possible for any employees and their dependents.  Include gender date of birth, diagnosis and date(s) of treatment.

 

All questions must be answered with either None or an explanation.

 

Treatment

Any receiving treatment in the past 5 years for cancer, kidney ailments, diabetes, heart conditions, psychological treatment, alcohol or drug disorders, transplant, etc.

None

Known Conditions

Any with known medical conditions who are expected to require hospitalization or surgery in the next 12 months

None

Mental or Physical Disabilities

Any with a history of or currently away from work due to mental or physical disability

None

Pregnancy

Any employee or dependent currently pregnant

None

COBRA

Any former employees or dependents on COBRA coverage

None

   

 

Employee Census

 

Please download this Excel file and complete your employee census.  This includes employees, COBRA participants and retirees.

 

Employee Census Excel File to Complete and Return

When you have completed all of the required information on this form, please press the submit button to send it to us.