ARG & Associates will provide you with a free, no-obligation Group Long-Term Care quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote.

Group Long-Term Care

Company Information

Company Name:                    Date:

Contact:

Address:

City:

State:

Zip:

Phone:                                Best time to call:   am    pm

Fax:

E-mail:

Business Type

Type of Business:           Industry Code:

Number of Employees:           Number of part time employees:

Please give a description of hazardous or dangerous duties any employee might perform for your company:

Insurance Information

Currently Insured with:

Policy Number:            Policy Expiration Date:

Premium Amount: $       Insured Amount: $

Term of Insurance:  6 months    1 year    other:

What type Group Health do you currently offer:  PPO    HMO    Other:

What type of plan/s do you offer?

Do you have coverage for medications?  Yes    No

What other types of insurance coverage do you have relating to your business? (Please list below):

Insurance Type                              Premium paid per Year                      Expiration Date

Business Liability                         $

Business Auto                             $

Business Umbrella                       $

Workers' Compensation                $

Professional Liability                     $

Liability for Corporate Executives   $

Group Health                               $

Group Life                                   $

Group Retirement/401k/etc.          $

Surety Bonds                              $

Other:           $

Current or previous Insurance Information

Do you currently have Long-Term care insurance policy, rider or certificate (including heath care or health maintenance:  Y    N

Did you previously have Long-Term Care insurance policy, rider or certificate in the past 12 months?:  Y    N If yes, please list (mm/dd/yy):

Are you covered by state assistance program:  Y    N

Do you intend to replace any of your medical or health insurance coverage with this policy, rider certificate:  Y    N

Does your company currently offer long-term care or disability benefits?  Y    N

Have you ever been denied coverage for medical insurance, disability insurance, long-term care insurance or life insurance?  Y    N

If you answered yes to any of the questions above please explain below:

Employee List for coverage

Employees. Name:          Sex:               Age:          # of Dep.:        DOB:              Zip Code:       Annual Salary:

1.      M    F

2.      M    F

3.      M    F

4.      M    F

5.      M    F

6.      M    F

7.      M    F

8.      M    F

9.      M    F

10.    M    F

11.    M    F

12.    M    F

13.    M    F

14.    M    F

15.    M    F

16.    M    F

17.    M    F

18.    M    F

19.    M    F

20.    M    F

21.    M    F

22.    M    F

23.    M    F

24.    M    F

25.    M    F

26.    M    F

27.    M    F

28.    M    F

29.    M    F

30.    M    F

If you require additional space please reset form after you send original information reuse form as many time as needed to complete your information. Please only fill in company name at the top and in the contact space fill in page number. (Example: Contact: Page 3 of 4)

Additional Details

Please list below any additional details in the space provided below:

When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly.

      

  This Form: GLTC2019 is a Copyright © 2003 First e-Commerce Corporation