CENSUS INFORMATION SHEET GROUP DISABILITY AND LIFE Group Name

Document Sample
CENSUS INFORMATION SHEET GROUP DISABILITY AND LIFE Group Name Powered By Docstoc
					                                                               CENSUS INFORMATION SHEET
                                                               GROUP DISABILITY AND LIFE




Group Name:
Group Phone:                                                 Group Fax:                                    E-mail Address:
Address:


County:
Contact Person:                                                                           Title:
Contact Phone:                                               Contact Fax:
How Long in Business
Name of Pennsylvania Medical Society Member:
Name of Current Carrier:                                                                   Current Monthly Premium:
SIC: 8011

Products Interested In:    (please check all that apply)

       Disability
           *Indicate Elimination Period:           LTD:             ____ 90-day            ____ 180-day
                                                   STD:             ____ 7-day             ____ 30-day
            *Indicate Duration:                    STD:             ____ 9 weeks           ____ 13 weeks           ____ 26 weeks
        Life
            Indicate Amount of Benefit:            ____ 2x Salary          ____ Specific Amount ($ _________________/employee)

*Elimination period is similar to a deductible. A 90-day elimination period means that disability payments will not start until after a 90 day period has been met
whereby an individual has been disabled for that amount of time. Elimination periods help to reduce the premium for group disability coverage. Please note that
price quotes can be generated for both 90- and 180-day elimination periods.

                                                                         Current
                                                                         In-Force
             Employee Name                        DOB       Gender       Coverage       State of         Annual                        Position/
           (indicate physicians)                                           Y/N?        Residence         Salary                    Title - Specialty




                      P.O. Box 69067 Harrisburg, PA 17106-9067 Fax: (717) 561-6077 (Confidential & HIPAA Compliant) Phone: 866-441-2392
                                               CENSUS INFORMATION SHEET
                                               GROUP DISABILITY AND LIFE




                                                        Current
  Employee Name                   DOB        Gender     In-Force        State of       Annual                      Position/
(indicate physicians)                                   Coverage       Residence       Salary                  Title - Specialty
                                                          Y/N?




          P.O. Box 69067 Harrisburg, PA 17106-9067 Fax: (717) 561-6077 (Confidential & HIPAA Compliant) Phone: 866-441-2392

				
DOCUMENT INFO
Shared By:
Stats:
views:6
posted:12/5/2010
language:English
pages:2
Description: PBX Telephone Exchanges in the original concept, as switching principle is to simply point and effective communication link. PBX business communications system is an important part, the main role in handling traffic for the extension, the relay traffic handling, traffic control and management, voice prompt processing and network technology based on traffic handling, processing based on optical fiber and wireless digital relay the mobile terminal, the internal integration of information transmission and other functions.