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.

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