1-800-462-2322
sales@allaboardbenefits.com

 

 

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Group Insurance

1-800-462-2322 (in USA)
All Aboard Benefits
6162 E. Mockingbird Lane #104
Dallas, Texas 75214 USA
voice: 214-821-6677   fax: 214-821-6676
The following form may be used to request a quote for group coverage. Tour groups, missionary groups, etc. need not complete the requested Employer-only information and salary fields.

When you have completed this form, please print to your printer. Then you can either Submit the form electronically or fax or mail it to us. You will receive a custom quote within 2 business days.

Group Quote Request Form

Please provide the following contact information:

Name of Group
Business
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Phone
FAX
E-mail

Does your group presently have group medical coverage?

Yes No

If yes, please fax or mail to us the following:

  1. Copy of policy or booklet describing benefits.
  2. Copy of most recent billing statement.
  3. Copy of most recent 3 years' claims experience.

Benefit Options Desired:

Deductible

Maximum Benefit

Prescription Drug Card

Yes No

Employers Only:

Waiting period - new employees

30 days
60 days
90 days
Other:

Please complete the following Census Data Table. Only Employers seeking coverage for employees need complete the Salary and Status* fields.

Status: E= Employee only, ES=Employee and Spouse Only, ECH=Employee and Child(ren), F=Employee and Spouse and (Children)

Group Census Data
Name (first, last) Sex Birth Date Country of Origin Annual Salary Status*

 

Employers complete the following. All other groups please skip to the next section.

Employers only! Please answer the following questions to the best of your knowledge. For Yes answers, provide additional details in the comment space provided below.
1. Has any employee or dependent suffered from a condition which resulted in a claim of $5,000 or more during the last 3 years?

Yes No
2. Are any employees or dependents currently pregnant?

Yes No
3. Are any employees or dependents currently hospitalized, confined at home, disabled or incapacitated?

Yes No
4. Are any employees not actively at work performing normal duties due to illness or injury?

Yes No
5. Are you aware of any circumstances or conditions which can be expected to produce an ongoing claim?

Yes No
6. Are any Eligible employees presently residing in the US or Canada?

Yes No
7. Are any Eligible employees presently on COBRA? Yes No
Additional Comments on the Above Questions (please identify comments with the question number):

 
Authorized Signature

Agent:  C. Michael Crowston
All Aboard Benefits
Agent Number: 99118
This information is intended to provide us with the information necessary to provide you with coverage and premium indications. Final rates and coverage will be based on the actual enrollment. No insurance is in effect until you are notified in writing. Thank you for your interest in Group Insurance.
Signature:



(Authorized representative of group)
Printed Name:


Date:

 

Please verify all information is correct, then print a copy of this completed form for your records. Click "Submit Form" only one time.
Submitting this form electronically constitutes a valid request for quote.  You may fax your completed form to 214-821-6676. A Signature is required only if sending via fax.

 

 

Last update: 04/28/2008
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