Group Insurance Services

Get a quote

Employer's Background Information

Employer's Legal Name:

Website Address:

State of Domicile:

Additional States:

Nature of Business:

SIC Code:

# of full-time W-2 employees

# of Employees that will be offered Select Benefits

Type of eligible employees

Full-Time

Part-Time

Hourly

Seasonal

1099's

Other

Effective date of coverage:

(Please allow four weeks before the effective date for enrollment processing. If less than four weeks, contact your Symetra Sales Representative.)

Plan Design

Target Price:

$ (per month) $ (per hour)

Rate Structure:

Composite (includes all dependents)

2 Tier

3 Tier

4 Tier

PPO Access (Additional fee applies):

Yes No

Number of plans:

Base/buy up plan design: Yes No

Projected Employer Contribution:

Plan Design Instructions:

Or you may complete this Plan Design Request Form and email it to GISproposalrequests@gisbenefits.com

Additional Information

Will employees eligible for Select Benefits be able to enroll simultaneously in Select Benefits and another medical plan offered by the employer? Yes No

If yes, is the medical plan a high deductible health plan with HSA? Yes No

Agent Information

Agent/Broker name: Symetra Financial start Number

Groups quoted in CT, GA, MT, NC, NM, PA, UT & WI must have an agent appointed prior to soliciting business. If you are not appointed with Symetra Financial, call 1-800-210-1106.

General Comments