Request A Quote - Employee Insurance Benefits Administrator, Life and Health Insurance Agency, Employers, Individuals - E. S. Beveridge & Associates

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Online Quote Request

Company Information
Company Name:
Contact:		Effective Date:
Location:		# of Locations:
Email Address:		Phone:
Nature of Business:		Fax:
Preferred Network:		SIC Code:
Hospital Affiliate:

Current Coverage
Type of Plan:	Fully Insured	Self-Funded	Minimum Premium
Carrier and/or Administrator:
Self-Funded, contract basis:
Employer contribution:	Employee %	Dependents %

Requested Coverage (Specific)
Annual Deductible Amount:
	12/12: Incurred and paid within the policy period
	15/12: Incurred within the policy period or 90 days immediately prior and with policy period
	12/15: Incurred within the policy period and paid within policy period or within 90 days
	Other:

Requested Coverage (Aggregate)
	12/12: Incurred and paid within the policy period
	15/12: Incurred within the policy period or 90 days immediately prior and with policy period
	12/15: Incurred within the policy period and paid within policy period or within 90 days
	Other:
Coverage Options:		Aggregate Accommodation	Terminal Extension

Benefits
Medical:	Yes	No
Prescription Drug Card:	Yes	No
Dental:	Yes	No
Vision:	Yes	No
Short Term Disability:	Yes	No

Current Enrollment
Total Number of Employees Eligible:
Total Number of Employees Participating:
Employee Coverage Count:
Employee/Spouse Coverage Count:
Employee/Child(ren) Coverage Count:
Family Coverage Count:

Rates and Factors (Current)
	Rates			Fully Insured Rates or Aggregate Factors
	Specific	Aggregate		Medical	Rx Card	Dental
Employee
EE/SP
EE/CH
Family

Rates and Factors (Renewal)
	Rates			Fully Insured Rates or Aggregate Factors
	Specific	Aggregate		Medical	Rx Card	Dental
Employee
EE/SP
EE/CH
Family

In order to process a quote we will need the following items:
	- Current Plan Document noting any changes you would like to make
	- Current Census stating age, sex, and coverage status
	- Claims experience for the past 3 years preferred (minimum 2 years)
	- Any medical claim(s) exceeding 50% of requested specific deductible

E. S. Beveridge &
Associates, Inc.
P.O. Box 636
Mansfield, Ohio 44901
419-525-3961
info@esbeveridge.com

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