Quote Request

Please fill out the form below to receive a quote
-or-
You can view our PDF by clicking here

Date Quote Requested:

Date Quote Needed:

Proposed Effective Date

COMPANY INFORMATION

Name of Company:

Type of Business:

Company Address :

City:

State:

Zip Code:

Telephone:	Number of Locations:
Group Contact:	Contact Number:
Email Address:	Company Website:

Client Objective(s): Price Benefit Service Other

PARTICIPANT INFORMATION

Currently have coverage: Yes No
Carriers Name:

Total # of Eligible Participants:

Total # of W-2 Employees:
PT
FT
Total # of 1099 Workers:

# Enrolled:

Monthly Premium:

Wait Peroid for New Hires:
30-Days 60-Days 90-Days
other

Employer Contribution:
Yes No

Employee: %

Dependent: %

Will the premiums be deducted on a Section 125 (pre-tax basis?)
Yes
No

Open Enrollment Peroid: 30-Days 60-Days 90-Days

Pay Cycle: Weekly Bi-Weekly Semi-Monthly Monthly

BENEFIT INFORMATION

Which AccessMD Plan would you like to offer your employees? Basic Plan Enhanced Plan Premium Plan
Plan Avaliability:
10-50 eligible employees, group can select 1 plan
51-250 eligible employees, group can select 2 plans
251+ eligible employees, group can select 3 plans

Optional Benefit(s):

Stand Alone

Dental

Vision

Group Term Life

Short Term Disability

Critical Care

AGENT INFORMATION

Soliciting Agent(s)/Broker(s) Name: Stephen Holmes

Agency Name: INSURANCE XCHANGE

Phone: (423) 894-0901

Fax: (423) 894-0907