Group Insurance Services

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Group Information

Group Name:

Address:

City:

State: Zip:

Telephone:

Email:

Nature of Business:

SIC Code:

Existing Coverage:

Eligible as a Take-over?:

Number of Employees:

# of Employees NOT actively at work:

Broker Information

Broker Name:

Address:

City:

State: Zip:

Telephone:

Email:

Fax:

GIS Senior Sales Consultant:

BCBST Rep:

Type of Quote (Please check all that apply)

Group Life
(Life amounts of up to $150,000 may be quoted according to job classification, a multiple of salary or a flat amount)

Employer Contribution

Flat Amount
$25,000 $35,000 Other $

Job Classification
Class I: Class II: Class III: Class IV:

Multiple of Salary
1 x Salary: 2 x Salary: Other:
(Salary must be provided for this option)

Group Dependent Life

Employer Contribution

Short Term Disability

Employer Contribution

Plan Options
1-8-3	1-8-26	1-8-52	8-8-13	8-8-26	8-8-52
15-15-13	15-15-26	15-15-52	30-30-13	30-30-26
Flat Amount: $ /Week (Provide salary for amount greater than $150 weekly)
% of Salary: % (Please provide salary)

Long Term Disability

Employer Contribution

Elimination Period: Benefit Duration:
Max Benefit Amount:
% of Salary: Definition of Disability: Other:

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