Bovard Insurance Group - Group Benefits Quote

Group Benefits Quote

Contact Name *

First

Last

Group/Company Name *

Main Location Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Preferred Method of Contact *

Phone E-mail

Industry Description Code or SIC Code: *

Employer Contribution - Employee Coverage (50% required for employee) *

Employer Contribution - Dependent Coverage *

Due Date *

Anniversary Date *

Name of current carrier *

Current Rates *

Name of prior carrier *

Number of years with current carrier *

Renewal Rates *

Number of years with prior carrier *

Life Insurance *

Coinsurance% *

Office Copay *

Deductible *

Out of Pocket *

Rx Copay *

Group Benefits Census Request
File Size:	58 kb
File Type:	xls

Comment *

6950 Squibb Rd., Suite 200
Mission, KS 66202
(913)529-1130 phone
(913)529-1137 fax