Employer Benefit Underwriters, Inc.

100 LaCosta Lane, Ste 120, Daytona Beach, FL 32114
Phone (386) 274-2600 * (888) 500-EBUI (3284) * Fax (386) 274-4111 * info@ebu-inc.com

Proposal Request From:
Address:
Phone: Fax: Today’s Date:
Group Name: Principal Location:
Industry: SIC Code:
Other Locations:
Due Date: Effective Date: Comm % :
Total Employees: Covered for Medical: Single: Family:
Employer Contributions Medical – Single: Medical – Family: Life:
Carrier Name or TPA if applicable

Fully Insured or Self Funded?

Specific
Rates

Life/AD&D Rates

Spec Ded. & Contract Basis

Agg Contract & Premium

Agg Factors
Single/Family

Renewal

 

 

 

 

 

Current

 

 

 

 

 

Prior

 

 

 

 

 


REQUESTED BENEFITS

Specific Deductible: $ $ $
Specific Contract: [ ] 12/12   [ ] 15/12   [ ] Other – Please list:
Specific Maximum: [ ] $1,000,000 standard   [ ] Other – Please specify:
Specific Advance? [ ] Yes  [ ] No Conversion Coverage? [ ] Yes  [ ] No
Aggregate Benefits:

[X] Medical

[ ] Dental

[ ] WI

[ ] Rx

[ ] Vision

Aggregate Contract: [ ] 12/12   [ ] 15/12   [ ] Other – Please list:
Aggregate Maximum: $1,000,000 standard Monthly Aggregate Accommodation? [ ] Yes  [ ] No
Please indicate requested benefits below and/or attach a copy of the current benefits:
Requested Plan: Ind. Deductible: Family Ded: Coinsurance:
OV Copay: Rx Card: Substance Abuse: Dental:
PPO Name:
Life: AD&D: [ ] Yes  [ ] No Dependent Life: Voluntary Life:
ATTACHMENTS including, but not limited to:
Census (Include age or year of birth, gender, coverage type [S/F], Life Amount, COBRA, Retired, etc.)
Claims and enrollment history, at least 2 years, including large claims