Small Group Health Quote
Requested Effective Date:
Employer Name:
Street Address:
City:
State:
Zip Code:
Country:
Telephone:
Fax:
Contact Name:
Nature of Business:
Current Carrier:
Renewal Date:
Eligible Employees:
Employees Enrolling:
Current Plan Design:
PPO
Open Access
POS
HMO
Employer Contribution %:
%
Plan Deductible:
Coinsurance:
Stop Loss:
Office Co-pay:
Hosp Co-pay:
Rx Card:
Alternate Plan Design:
PPO
Open Access
POS
HMO
Plan Deductible:
Coinsurance:
Stop Loss:
Office Co-pay:
Hosp Co-pay:
Rx Card:
Optional Benefits:
Life/AD&D Amount $
or
Times Salary to a maximum of $
Dental
Deductible,
/
/
/
Coinsurance, Plan Maximum
Short Term Disability
% of salary to a weekly maximum of
Long Term Disability
% of salary to a weekly maximum of
401(k)
Other
Employee Name
Date Of Birth
Sex
Enrollment Status*
Employee Zip Code
Employee Occupation**
Employee Salary
* Please use the following Enrollment Status Codes
SGL = Single Employee
H&W = Employee & Spouse
P&C = Employee&Child(ren)
FAM = Family
Waiver = No benefits
( Note any employees who are on COBRA/NJ Continuation)
Include with Census:
Current billing statement
Current Benefit Booklet
Renewal data
** Required information for LDT/STD and multiple of salary Life coverage
Return To:
DGS Benefits, Inc.
79 Chestnut Street
Ridgewood, NJ 07450
Tel: 201-447-2229
Fax: 201-447-2464
