PhoneThis field is for validation purposes and should be left unchanged.Applicant InformationApplicant Entity Type:(Required) Individual Partnership Corporation LLC Joint Venture Other Applicant Name:(Required)Applicant's Name:(Required) First Last Applicant's Company Name:(Required)Owner's Name:(Required) First Last Business Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is business address the same as mailing address?(Required) Yes No Mailing Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:(Required)Fax:Email:(Required) Website FEIN (Tax ID #):(Required)Does the applicant have a DBA (Doing Business As) name:In what year did the applicant start operations?(Required)2026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900Please the applicant's day-to-day business operations:(Required)Main area of practice, type of services provided, products, etc. - Please be detailedAre there any locations or business interests that are owned by the applicant but not shown on the application?(Required) Yes No Are there high-valued goods, including merchandise at your location?(Required) Yes No If yes, what is the approximate value of your inventory?(Required)Please enter a number greater than or equal to 0.What is the value of your business personal property? (BPP are all your furniture, printers, etc. Basically, anything you will take with you if you move)(Required)Please enter a number greater than or equal to 0.Employee & Eligibility InformationTotal Number of Employees:Full-Time Employees(Required)Please enter a number greater than or equal to 0.Part-Time Employees(Required)Please enter a number greater than or equal to 0.Seasonal/Temporary Employees(Required)Please enter a number greater than or equal to 0.How many employees are eligible for health insurance coverage?(Required)Please enter a number greater than or equal to 0.How many employees are currently enrolled in a health insurance plan?(Required)Please enter a number greater than or equal to 0.Do you wish to provide coverage for:(Required) Employees Only Employees & Dependents Employees, Dependents & Spouses Do you have a waiting period for new employees?(Required) Yes No If yes, how long? (30 days 60 days 90 days other)(Required)Do you currently offer health insurance to employees?(Required) Yes No If yes, who is the current insurer?(Required)What is the policy effective date?(Required) MM slash DD slash YYYY What is the policy expiration date?(Required) MM slash DD slash YYYY Plan Coverage & BenefitsWhat type of coverage are you looking for? (Check all that apply)(Required) Medical Insurance Dental Insurance Vision Insurance Life Insurance Disability Insurance (Short-Term & Long-Term) Health Savings Accounts (HSA) or Flexible Spending Accounts (FSA) Wellness Programs Preferred Plan Type(s):(Required) PPO (Preferred Provider Organization) HMO (Health Maintenance Organization) POS (Point of Service) HDHP (High Deductible Health Plan) Desired Employer Contribution Toward Premiums:(Required) 100% Employer-Paid 75% Empolyer-Paid 50% Employer-Paid Other Would you like additional voluntary benefits for employees (e.g., critical illness, accident insurance, supplemental coverage)?(Required) Yes No Please list which additional benefits you are interested in:(Required)Employee Health & DemographicsPlease provide a census of employee, including: (Attach spreadsheets if available) Employee Name (or ID) Date Of Birth Gender Job Title Work Location (state) Employment Status (Full-Time/Part-Time) Current Health Plan (if applicable)FileMax. file size: 50 MB. Are any employees currently on COBRA coverage?(Required) Yes NO Are there any retirees who need coverage?(Required) Yes No Insurance History & Claims InformationHave you had group health insurance coverage in the past?(Required) Yes No If yes, name the current or previous insurer:(Required)Policy expiration date:(Required) MM slash DD slash YYYY Have you experienced any significant rate increases in the past three years?(Required) Yes No If yes, please provide details:(Required)Have you had any high-cost claims (over $25,000) in the past three years?(Required) Yes No If yes, Please provide details:(Required)Additional Comments or Special Considerations(Please provide any other relevant information that may impact your insurance coverage needs.) Δ
