Agent Request A Quote

Please complete the following form and click submit.
My Name Is
Company Name
Address
Phone Number
Type Of Industry
Current Coverage:	if Yes, Name of Carrier
Number of Employees

A Direct Self Funded Quote will reduce your cost by 10% to 15%. If you desire a quote utilizing an agent, please complete the agent information at the bottom of this section. Self-Funded Quotes limited to 25+ lives. Assured Benefits Administration contact number 800-247-7114.
My Name is:
My Company Name is
My Address is:
My Phone Number is:
My Email is:
Nature of Business:
Do you currently have group medical coverage/
Proposed Effective Date
Date Quote Required
Current Rates if Fully Insured:
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Current Rates & Data if Self Insured:
Specific Deductible
Aggregating Specific
Specific Basis:
Specific Rates:
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Do the above rates include commissions?
Coverage Includes:	Medical Dental Rx Vision
List of Lasers:
Aggregate Premium
Aggregate Basis:
Aggregate Factors:
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Aggregate Accommodations
Managed Care Networked Desired:
Coverage Includes:	Medical Dental Rx Vision
Remarks
Agent Informaiton
Agent Name
Agency Name
Agent Contact Phone Number
Please attach census and plan of benefits desired and fax to 915 543-6350 or email to saustin@abadmin.com

Self-Funded Quotes limited to 25+ lives. Assured Benefits Administration contact number 800-247-7114.
Agents Name:
Agency Name: (if Applicable)
Agents Address:
Agents Phone Number:
Agents Email Address:
Name of Case Presented:
Nature of Business:
Address:

City/State/Zip
Proposed Effective Date
Date Quote Required
Current Rates if Fully Insured:
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Current Rates & Data if Self Insured:
Specific Deductible
Aggregating Specific
Specific Basis:
Specific Rates:
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Coverage Includes:	Medical Dental Rx Vision
List of Lasers:
Aggregate Premium
Aggregate Basis:
Aggregate Factors:
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
Aggregate Accommodations
Managed Care Networked Desired:
Coverage Includes:	Medical Dental Rx Vision
Remarks
Please attach census and plan of benefits desired and fax to 915 543-6350 or email to saustin@abadmin.com

The current Group Medical Plan is and the effective date is .
Please indicate contact information and a marketing representative will call on the date selected to discuss providing a self-funded qoute.
Name
Company Name
Date to Call
Phone number to call or email ,if desired, to discuss further.

Please complete the following form and click submit.
My Name Is
Company Name
Address
Phone Number
Type Of Industry
Current Coverage:	if Yes, Name of Carrier
Number of Employees

Fully Insured, 1 to 50 lives

Agents Name:

Agency Name: (if Applicable)

Agents Address:

Agents Phone Number:

Agents Email Address:

Name of Case /Individual

Address

City/State/Zip

SIC Code is Applicable:

If not known, what type of
business is this employer engaged in:

Desired Effective Date:

IAC Plan Desired:

	Sex	DOB/Age	Coverage	Coverage Type