Group Life Request Form

* Asterisk indicates Required Field

South Pacific Insurance Agency

Request for a group quote

This form is not required for quoting. It is for you convenience and to ensure that we have all the information needed to provide you with a correct quote in a timely manner. Please fill in what you would like.

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Return Method:

FaxMailBocker Pick-UpEmail

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Will the employees be required to contribute toward the cost of the insurance? *

YesNo

If yes, what is the percentage of the cost of coverage that the employer will pay?

Life Insurance
AD&D

To quote, we will need census containing, D.O.B., sex, salary, class # if on a class schedule.

Short Term Disability

Waiting Period:

To quote, we will need census containing D.O.B., sex, salary.

Long Term Disability

Own Occupation:

2yr3yr5yrTo Age 65

Pre-Existing Conditions:

3/6/1212/6/246/12/24

Definition of Disability:

Parial:

YesNo

0 Day Residual:

YesNo

Contributory:

YesNo

To quote, we will need census containing D.O.B., sex, salary, occupations and classes if 2 or more. Experience is needed if over 100 lives.

Dental

Deductible:

$25$50$100

Family Limit:

2x3x

Waived for Prev:

YesNo

Coinsurance:

Calendar-Year Maximum:

$1000$1500$2000

Orthodontia:

YesNo

Contributory:

YesNo

To quote, we will need census containing D.O.B., sex, spouse, child and renewel in force now.

Important Notice

Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.