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.

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