Alaskan Benefit Insurance Consultants

1) Company Name: (required)

2) Company Address: (required)

3) Company Phone: (required)

4) Fax:

5) Your Email (required)

6) City (required)

7) State (required)
Alaska

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 Census Form *
Please List Below All Full-Time eligible employees and dependents: You can forward an EXCEL spreadsheet with the required information to abic@customcpu.com if this is easier, or fax this to 907.243.1411.

Name Date of Birth
M or F Spouse/#Children *Occupation
*Annual Earnings * Smoker Y/N

SAMPLE: John Doe,7-54,M,SPOUSE 3, OFFICE MGR, 36,000.,N
* OCCUPATION, ANNUAL EARNINGS, AND SMOKER DESIGNATION UNNECESSARY UNLESS DISABILITY OR LONG TERM CARE COVERAGE REQUESTED. (required)

25) 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)