Fillable S MALL GROUP PROPOSAL REQUEST 1 BROKER (Dickerson Insurance Services)

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S MALL GROUP PROPOSAL REQUEST 1 BROKER (Dickerson Insurance Services)

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Company/Group Name: _____________________________________
Address: _________________________________________________
City: _____________________________________________________
State: ____________________ ZIP Code: _______________________
Coverage Outside CA?: ________________ Virgin Group: Y N
SIC: ___________ or Nature of Business: _______________________
Name: ___________________________________________________
Agency: __________________________________________________
Address: _________________________________________________
City: _____________________________________________________
State: ____________________ ZIP Code: _______________________
License #: ____________________Covered CA Certied: Y N
5-24-19
For more Information N. CA call: (877) 361-7342
For more Information S. CA call: (800) 457-6116
License #0M29112
1 BROKER
2 GROUP
3 COVERAGE
Phone: ________________________ Fax: _______________________
Email: ____________________________________________________
Insurance Lines: ___________________________________________
Dickerson Exec: ___________________________________________
Renewal Date: _____________ Eective Date:___________________
Current Medical Carrier: _____________________________________
Current Premium: $ ________________________________________
Current Dental Carrier: _____________________________________
Current Dental Premium: $ __________________________________
Life Amount: $ _________________________
Medical: HMO PPO EPO
Dental
Vision
Life
Employer Contribution: EE % DEP %
STD
LTD
ACC
AD&D
CI
Chiro
Acupuncture
Hospitalization
Workers’ Comp
4 SPECIAL INSTRUCTIONS
Mail Email Fax Pick-up
One of the advantages of working with Dickerson Insurance Services —
we can manage the entire quoting process for you. It’s easy to get started.
S
MALL GROUP PROPOSAL REQUEST
Payroll
Electronic Enrollment
ERISA
HSA
HRA
Self-Funded
GAP
MEC/MVP
5 SUBMIT COMPLETED FORM & CENSUS
Via email: quotes@dickerson-group.com
Via fax Southern CA: (323) 805-2905
Via fax Northern CA: (888) 360-7342
www.thebrokersga.com
First Name, Last Name
DOB
mm/dd/yyyy
Age
Medical
Status
Dental
Status
Vision
Status
ZIP Code
for EE
M/F
COBRA
Y/N
Salary***
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Account Executive: _________________________________________
Company/Group Name: _____________________________________
Broker: ___________________________________________________
Email: ____________________________________________________
GROUP CENSUS
Required Medical Status Code (choose 1)
for Employees (EE) for Dependents
EE=Employee Only
ES=Employee/Spouse
EF=Employee/Family
EC=Employee/1 Child, EMC=Employee/Children
SP=Spouse, DP=Dependent
Dental Status Code
(choose 1)
Vision Status Code
(choose 1)
EE, ES, EF
EC, EMC
EE, ES, EF
EC, EMC
***only when quoting LTD, STD and higher amount of Life
1-39
First Name, Last Name
DOB
mm/dd/yyyy
Age
Medical
Status
Dental
Status
Vision
Status
ZIP Code
for EE
M/F
COBRA
Y/N
Salary***
40
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Account Executive: _________________________________________
Company/Group Name: _____________________________________
Broker: ___________________________________________________
Email: ____________________________________________________
GROUP CENSUS
Required Medical Status Code (choose 1)
for Employees (EE) for Dependents
EE=Employee Only
ES=Employee/Spouse
EF=Employee/Family
EC=Employee/1 Child, EMC=Employee/Children
SP=Spouse, DP=Dependent
Dental Status Code
(choose 1)
Vision Status Code
(choose 1)
EE, ES, EF
EC, EMC
EE, ES, EF
EC, EMC
***only when quoting LTD, STD and higher amount of Life
40-79
First Name, Last Name
DOB
mm/dd/yyyy
Age
Medical
Status
Dental
Status
Vision
Status
ZIP Code
for EE
M/F
COBRA
Y/N
Salary***
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Account Executive: _________________________________________
Company/Group Name: _____________________________________
Broker: ___________________________________________________
Email: ____________________________________________________
GROUP CENSUS
Required Medical Status Code (choose 1)
for Employees (EE) for Dependents
EE=Employee Only
ES=Employee/Spouse
EF=Employee/Family
EC=Employee/1 Child, EMC=Employee/Children
SP=Spouse, DP=Dependent
Dental Status Code
(choose 1)
Vision Status Code
(choose 1)
EE, ES, EF
EC, EMC
EE, ES, EF
EC, EMC
***only when quoting LTD, STD and higher amount of Life
80-119
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S MALL GROUP PROPOSAL REQUEST 1 BROKER (Dickerson Insurance Services)

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Completed 1 June 2021

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