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Michael W. Smith Agency

Revised:

May 06, 2015

Employee Benefits

 763-535-7293

 

 

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We feature a full line of Health Care Insurance Plans including Major Medical Plans, HMO Plans, Critical Illness, HSA Plans, Cafeteria Plans, Dental Insurance & Short & Long Term Disability Income from Companies such as Delta Dental, Assurant Heath, HealthPartners, MEDICA & MetLife.

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Small Group Health Care Rate Quote Request Form

This is a request for a Minnesota small group health insurance quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Group health insurance rates are subject to change

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Name
Company Name
Street
City, State ZIP

     

County Located
E-mail
Phone
Fax

General Information on Your Employees

Total Number of Employees Number working more than 20 hours/week Number working more than 20 hours/week waiving coverage
     
Number of Employees participating Number employed in Minnesota More than 49 employees in the previous calendar year?
    Yes No

General Information on Employer

Percentage Employer contributes toward Employee Cost Current Health Care Carrier Renewal Date

Companies Plans Requesting Information On

Blue Cross and Blue Shield of Minnesota
Blue Plus of Minnesota
Health Partners
MEDICA
Assurant Health

Additional Benefits

Life Insurance Yes No
Short Term Disability Insurance Yes No
Long Term Disability Insurance Yes No
Critical Illness Insurance Yes No
Health Savings Account (HSA) Yes No
Dental Insurance Yes No
If yes, do you have Dental Insurance now Yes No

Employee Census

(The Employee Name is optional, Sex and Employee Date of Birth (DOB) are mandatory, Spouse's DOB must be included if requesting coverage, Children's ages must be included if requesting coverage and should be separated by commas, Monthly Salary is needed if requesting Disability Benefits).
 

Employee Name

Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
 

Employee Name

Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
  Employee Name Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
  Employee Name Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
  Employee Name Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
41.
42.
43.
44.
45.
46.
47.
48.
49.

Please comment on any employees over 65 and not on Medicare.

Additional Comments

 

 

 

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Copyright 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 Michael W. Smith Agency