Information needed for a Bend Chamber of Commerce Group Health Insurance quote
Current Coverage
Do you have dental coverage? Yes No
If Yes, Name of Carrier
Do you have vision coverage? Yes No
Is the current plan a group or an individual plan Group Individual
Current Insurance Carrier
Current policy effective date (Format DD/MM/YYYY)
Information regarding current policy
Current Group Rate (required information)
Group Census
List ALL (and only) employees in the box below (First name, gender, date of birth, number of hours worked per week, and tier code) i.e. Joe, Male, MM/DD/YYYY, 25, ES Tier Code: EE - Employee Only ES - Employee and Spouse EF - Employee and Family EC - Employee and Child(ren) W - Waiving Coverage to other group plan
BUSINESS FINDER
