Alaskan Benefit Insurance Consultants

Business Form

Please complete the following form and click Submit. We will contact you as soon as possible regarding your request. The average time to complete a group quotation is 1 1/2 weeks. Please send census information via EXCEL or a pdf. file. to abic@customcpu.com .

1) Company Name: (required)

2) Company Address: (required)

3) Company Phone: (required)

4) Fax:

5) Your Email (required)

6) City (required)

7) State (required)

8) Zip Code (required)

9) Requested effective date: (required)

10) Company Contact and nature of business or SIC CODE / industry: (required)

11) Current Carriers Name and #Years: (required)

12) Deductibles
250 500 1000 1000+ Health Savings Account A variety of plan choices

13) Coinsurance
80%/20% to $5,000 $10,000 BOTH

14) Coinsurance
50%/50% to $5,000 $10,000 BOTH

15) DOCTORS OFFICE CO-PAY PLAN
Yes No

16) Prescription Drug Card
Yes No $15/$25/$40 $10/$20/$40 $5/$10 $5/$15/$30 $10/$20 $5/$15 A VARIETY

17) Life Accident Death and Dismemberment
$10K $15K $20K $25K $50K X salary

18) Dental
Yes No

Deductible
$25 $50 $100

Annual Max
$1K 1.5K $2K 2.5K

Ortho
Yes No

19) Vision
Yes No

20) Short Term Disability
Yes No
$250 $500 $1000 weekly

21)Long Term Disability
Yes No

Monthly Max
$1K 2K $3K $5K

Elimination Period Days
30 60 90 180

22) Special Needs Supplemental Coverage
Travel Accident Cancer Accident Intensive Care

23) Section 125 Cafeteria plan Pre-Tax Dollar For Flexible Benefit Options
Yes No

24) Employee #1 Census Form*
Please List Below All Full-Time eligible employees and dependents. If you prefer, you can forward an EXCEL spreadsheet with this information to abic@customcpu.com or fax it to 907.243.1411.

Example: John Doe,7-54,M,SPOUSE, 3, OFFICE MGR, 36,000.,N, Pregnant due 12/08

Note: * OCCUPATION, ANNUAL EARNINGS, AND SMOKER DESIGNATION FIELDS ARE UNNECESSARY UNLESS DISABILITY OR LONG TERM CARE COVERAGE REQUESTED. (required)

Name:

Date of Birth:

M or F:

Spouse/#Children:

*Occupation:

*Annual Earnings:

* Smoker Y/N:

Any known major health conditions? Employees or Dependents? Please indicate Employee number and condition

SAMPLE
#1 Pregnant due 12/08, #2 Heart attach 3-03 triple bypass, #3 spouse
high blood pressure stable with medication. If none are known please
state unknown.(required)

25) Employee #2 Census Form*
Please List Below All Full-Time eligible employees and dependents. If you prefer, you can forward an EXCEL spreadsheet with this information to abic@customcpu.com or fax it to 907.243.1411.