WorkingAmericanBenefits™

                                                                 
Product Selection:

Select the insurance company, the type of health insurance, the co-pay, the deductible and the coinsurance for which you would like to receive a quote.  Along with your health insurance selections, you may select ONE of each of the other types of insurance for which you may need a quote.  Submit additional copies of this form if the number of employees exceeds 25.

       Health Insurance                                      Company                                   Deductible/CoIns.      Copay

    Major Med. PPO - 80/20         Select American Medical Security - Wisconsin Life Assurant Health Humana Insurance Company Choose a good company for me       Select $250 / $1000 $250 / $2000 $250 / $5000 $500 / $1000 $500 / $2000 $500 / $5000 $500 / $7500 $500 / $10000 $750 / $1000 $750 / $2000 $750 / $5000 $750 / $7500 $750 / $10000 $1000 / $1000 $1000 / $2000 $1000 / $5000 $1000 / $7500 $1000 / $10000 $1500 / $2500 $1500 / $3000 $1500 / $5000 $1500 / $7500 $1500 / $10000 $2500 / $5000 $2500 / $7500 $2500 / $10000 $5000 / $10000       Select $5 $7 $10 $15 $20 $25 $30 $35 $40

    Major Med. PPO - 70/30         Select American Medical Security - Wisconsin Life Assurant Health Humana Insurance Company Choose a good company for me       Select $250 / $1000 $250 / $2000 $250 / $5000 $500 / $1000 $500 / $2000 $500 / $5000 $750 / $1000 $750 / $2000 $750 / $5000 $1000 / $1000 $1000 / $2000 $1000 / $5000 $1000 / $10000 $1500 / $2500 $1500 / $5000 $1500 / $10000

    Major Med. PPO - 50/50          Select American Medical Security - Wisconsin Life Assurant Health Humana Insurance Company Choose a good company for me       Select $250 / $1000 $250 / $2000 $250 / $5000 $500 / $1000 $500 / $2000 $500 / $5000 $500 / $8000 $750 / $1000 $750 / $2000 $750 / $5000 $750 / $8000 $1000 / $1000 $1000 / $2000 $1000 / $5000 $1000 / $8000 $1000 / $10000 $1500 / $2500 $1500 / $3000 $1500 / $5000 $1500 / $8000 $1500 / $10000 $2500 / $5000 $2500 / $7500 $2500 / $8000 $2500 / $10000 $5000 / $8000 $5000 / $10000

    Major Med. PPO - 100/0         Select Assurant Health American Medical Security - Wisconsin Life Choose a good company for me       Select $500 / $0 $750 / $0 $1000 / $0 $1500 / $0 $2000 / $0 $2500 / $0 $5000 / $0 $7500 / $0 $10000 / $0 .............................

    Major Med. HMO                     Select Medica Health Plans Humana Insurance Company of Florida, Inc Vista Health Plan Choose a good company for me       Select None .............................

    Major Med. POS                    Select None ____________________________________.       Select None .............................

    Mini Medical                           Select AIM Guranteed Issue Limited Benefit Plans CareAccess Health Plan USNow Guaranteed Issue Ltd. Benefit Plan Choose a good company for me          Select None .............................

       Disability Insurance                                  Company                                  Monthly Benefit

    Short Term Disability            Select Allstate Financial --- Amercan Heritage Life Colonial Supplemental Insurance Fort Dearborn Life Insurance Co. Illinois Mutual Life Insurance Co. ING - Relia Star Life Insurance Co. UnumProvident Life Insurance Co. Assurity Life Insurance Company Fideelity Security Life Insurance Co.       

    Long Term Disability          Select Fort Dearborn Life Insurance Company Illinois Mutual Life Insurance Company ING - Relia Star Life Insurance Company UnumProvident Life Insurance Company Assurity Life Insurance Company Fidelity Security Life Insurance Co. ____________________________________       

       Dental/Vision Plans                                  Company                                  Plan of Insurance

    Group Dental Plan                Select American Medical Security Colorado Bankers Life Insurance Co. FORTIS Insurance Company Guardian Life Insurance Company                

Company Information:  (Required)

Employer/Co. Name:        Co. Contact:  

Employer/Co. Address:      Suite No.:     

City:                                               State:   - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip Code:   

Contact Phone:                 Fax:          E-mail:  

Employee Information:  (Required)

Key:  M - Male;    F - Female;      EE    - Eligible Employee only;        SP  - Employee and Spouse;     CH   - Employee and Child

                                                         CH+ - Employee and Children;       FM - Employee and Family;      E+1  - Employee + 1     

                                                Date of Birth         Gender        Emp. & Dependents                   Plan Type                   Dental 

                Employee Name                    mm/dd/yyyy            M       F        EE    SP   CH    CH+ FM       HMO  PPO  POS      EE   E+1  FM
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IMPORTANT!                IMPORTANT!

If you were told about this website by an agent, please enter the agent's name and agent number (If known) in the space below.  This information may be found on the agent's business card or on a flyer or correspondence given to you by the agent:

Agent's Name:        Agent Number: 

Congratulations!  You have now completed your request for a quote.  Please click on  the SUBMIT button below to submit your request for processing.   Please check your e-mail at the e-mail address you provided above for confirmation of the receipt of your request for a quote.    If you do not receive your quote within a reasonable period of time, please call our customer services department immediately at (954)430-8475 or send us an e-mail at customer_service@workingamericanbenefits.com.