Foster Benefit Resources - Group insurance online quote

Group Insurance Quote Request

For groups larger than 25 lives please fax in a quote at 972-960-8854
Or E-Mail to this address: rates@fosterbenefits.com

Agent Name:

(Required)

Agent Company:

(Required)

Email Address:

(Required)

Address 1:

Address 2:

City:

State:

Zip Code:

Phone:

Fax:

Group Information

Group Name	(Required)
City	(Required)
Zip Code	(Required)
Effective Date:	ie. MM-DD-YY (Required)
Nature of Business:	(Required)
Sic Code:
Current Carrier:	(Required)
Cobra Employees:
United Healthcare Benefit Information UHC Contributions and Participation Requirements Medical Employer Contribution - 50% Employee Participation - 75% Life Employer Contribution - 25% Employee Participation - 75% If contribution is 100%, then 100% participation is required Dental Employer Contribution - 50% Employee Participation - 75%, but 50% of the total group is required to enroll


Medical Plan: Please list preferred medical plans or leave blank for FBR to choose.
(HSA plans are only available with RX H9) RX Plan: Please list preferred rx plan or leave blank for FBR to choose.
Life Insurance: (If No go to next section) (All amounts are in increments of $5,000)
Dependent Life: (If No go to next section)
Dental PPO plans (If none go to next section): Top Selling DentalGrid_TX.pdf
Please indicate a plan from the Top Selling Dental Grid or leave blank for FBR to choose.
Ortho Orthodontia is available to groups of 10+ eligibles and 8 enrollees.


UHC Dental Indemnity Plans (For multi-sites only): Dental_Product_Grid2_05.pdf
If yes, please indicate a plan from the Dental_Product_Grid2_05.pdf file or leave blank for FBR to choose.
Hartford

Hartford Std:
Hartford LTD:
Harford Life : Life Amounts
Ameritas
Ameritas Dental (available on 3+ lives)
Takeover: (available only on 5+ lives)
Vision: (available on 3+ lives when sold with dental and 10+ when sold as a stand alone)
Medical Conditions
Please tell us about any medical conditions :

Sex

Health

Age

Zip Code Date of Birth
(MM/DD/YYYY)

Dependent Status *

Annual Salary (Disability or x salary life)

*Dependent Status Key

EE= Employee Only

EC=Employee & Child

ES=Employee & Spouse

EB=Employee & Family