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Group Health Proposal Request

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Agent Information
First Name* Last Name*
Phone* ()  -
Email*
Address
City State Zip
Your INA Employee Benefit Specialist (if known)

*Required Information
Client Information
Client Name (person or company)   Total Number of Employees  
Requested Effective Date   Number of Employees Enrolling  
City State Zip County
Nature of Business or SIC Code

Medical Quote
Options you would like to see for this client. Check all option that apply.
Health Saving Account  Health Reimbursement Arrangement  Partially Self-Funded Plan  Gap Plan  Traditional Fully-Insured
Proposed Benefits:
Requested Quotes
Employer Contribution
Medical Deductible
Coinsurance
Stop Loss
Office Copay
Drug Card
Maternity
Preventive
Supplement Accident
Plan 1
EE Dep
Plan 2
EE Dep
Plan 3
EE Dep
Known medical conditions:
Ancillary Plan Information
Dental Quote
Employer Contribution      EE Dep
Dental Deductible
Dental Maximum
Orthodontics
Life Quote
Class 1
Class 2
Class 3
Short Term Disability 
Class 1
Class 2
Class 3
Weekly Benefits  Standard Plan: 1/8/26, 60% of income
Long Term Disability:
Contact your Insurance Network Marketing Consultant. Phone 1-800-456-7999.
Census Information
Please attach a document containing the client's employee census, or complete the census form below.
Census File    (file will be ignored if larger than 3 megabytes)


EE Name Birthdate
or age		 Sex Medical Coverage
EE, ES, EC, FF, None		 Dental Coverage
EE, ES, EC, FF, None		 Number Children Annual Salary
Needed only for Disability or Life		 Disability Class Life Class
*EE=Employee only   ES=Employee and Spouse only   EC=Employee and Child(ren) only   FF=Employee, Spouse and Child(ren)  
Census Notes
Notes regarding medical conditions or other information:



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