 | ||||
|
|
|
|
QUOTE INFORMATION FOR INSURANCE SOURCE, LLC SMALL GROUP 2-50 EMPLOYEES GROUP INFORMATION Group Name: ______________________________________________________ Contact Person: ____________________________________________________ Address: State: LA Zip: ___________ Parish: ___________________________________ Nature of Business: _________________________________________________ Present Health Insurance Carrier: _______________________________________ Effective Date Requested: _____________________________________________ Dental: Y or N Disability: Y or N (If yes, please include salary information) BROKER INFORMATION BROKER: DWAYNE WILSON BATON PHONE: 225-933-9626 FAX: 225-751-6165 EMPLOYEE BIRTHDAY/AGE SEX *TYPE OF COVERAGE SPOUSE/AGE # OF CHILDREN 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ 4.____________________________________________________________________________ 5.____________________________________________________________________________ 6.____________________________________________________________________________ 7.____________________________________________________________________________ 8.____________________________________________________________________________ 9.____________________________________________________________________________ 10.___________________________________________________________________________ 11.___________________________________________________________________________ 12.___________________________________________________________________________ 13.___________________________________________________________________________ 14.___________________________________________________________________________ 15.___________________________________________________________________________ 16.___________________________________________________________________________ 17.___________________________________________________________________________ 18.___________________________________________________________________________ 19.___________________________________________________________________________ 20.___________________________________________________________________________ 21.___________________________________________________________________________ 22.___________________________________________________________________________ 23.___________________________________________________________________________ 24.___________________________________________________________________________ 25.___________________________________________________________________________ *EO = EMPLOYEE ONLY ES = EMPLOYEE/SPOUSE EC = EMPLOYEE/CHILDREN F = FAMILY |
Copyright 2007 Insurance Source, LLC All rights reserved. Terms | Login