For an instant quote on your Group Disability Insurance, fill out the preliminary form below and an agent will contact you. We will not distribute your name, e-mail, phone or address to others.

General Information Legal Name of Business: Contact Name: Address: City:   State:   Zip: Business Phone:   Fax: Best Time To Call:   AM   PM Contact Email Address:

Type of Business Type of Business: Standard Industry Code (if known): # of Full Time Employees:         # of Part Time Employees: Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Disability Carrier Information Carrier (Company) Name (not agency): Please give a brief description of your current Group Disability plan:

Benefits Desired Major Medical Deductible: $200$250$300$500$1,000     Optional Pregnancy Coverage: yes no Dental Coverage: yes no  Supplemental Accident Coverage: yes no Disability Insurance: yes no  PCS Card: (Prescription Discount Option) yes no Group Life Insurance:       Amount: yes no  $ PPO Option: yes no HMO Option: yes no

Employee Information Please list all employees you wish to cover: Employee Name Date of Birth Age Sex Dependent Status M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or email an additional listing.

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

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Pacific Benefit Consultants, Inc. 450 Country Club Rd. Suite 330 Eugene, Oregon 97401 (541) 484-6624 (541) 686-2726 (Fax) (800) 588-8688 (Toll Free)

 

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