Annual Employee Cost
X
$350
=
Number of Employees
Annual Cost per Employee
112% of Claims Submitted
Maximum Cost
X
=
Number of Employees
Premium Factor
Maximum Employer Liability
Maximum Benefit
X
=
Number of Employees
Average Benefit
Maximum Employee Benefit
Effective Date
*
Company Name
*
Company State
*
Alabama
Alaska
Arizona
Arkansas
California
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kentucky
Louisiana
Maine
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
West Virginia
Wisconsin
Wyoming
Agent Name
Phone Number
*
E-Mail Address
*
# of Participants
Benefit Per Participant
Minimum # of Participants
$10,000
10
$15,000
5
$20,000
5
$25,000
4
$35,000
4
$50,000
3
$75,000
3
$100,000
1
$200,000
1
The above information is being submitted to request a proposal for insurance coverage.
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