Group Insurance Services

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Group Information

Group Name:

Address:

City:

State: Zip:

Telephone:

Email:

BCBST Group #:

Nature of Business:

SIC Code:

Existing Coverage:

Eligible as a Take-over?:

Number of Employees:

# of Employees working outside the state of TN:

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)

Dental	Prime Plan w/out Ortho	Prime Plan w/ Ortho	Choice Plan	All Plans	DentalBlue
Vision	Plan A1	Plan A2	Plan B1	Plan B2	All Plans	VisionBlue
Life	With Portability	Without Portability	Blended Rates		Tobacco Distinct Rates

Short Term Disability
With Continuity of Coverage	1-8-13	1-8-26	1-8-52	8-8-13	8-8-26	8-8-52
Without Continuity of Coverage	15-15-13	15-15-26	15-15-52	30-30-13	30-30-26

Long Term Disability

90 day

180 day

5 Yr. 2 Yr.

5 Yr. 5 Yr.

To Age 65

Limted Medical Benefit Plan

GAP / Supplemental Medical

To be sold in conjunction with Medical plan

(*Additional information may be required to complete proposal request. Please contact GIS for more info.)

# Eligible (seasonal, temp, part-time, etc., not total # employees):
#1099 Employees:
% Employer Funded:

Specialty Products

Cancer

Accident

Critical Illness

Hospital Indemnity

Rate Selection

Weekly

Bi-Weekly

24-pays

Monthly

Effective Date of Group:

How would you like to receive your quote(s)? Email Fax Do you need appointment papers?

Email Address (if different from above)	Fax Number ` (if different from above)