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Forms:

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Fax or e-mail your request to : (888) 732-8945 or quotes@gmsil.com

Individual Major Medical

Over 65

Ask for rate card

Under 65

First Name
Last Name
Gender
Date of Birth
Zip Code
Smoker Y/N
Dental Y/N

Dep Info: » Name » Date of Birth » Gender

Group Major Medical

Name of Business
Location (zip code)
Phone Number
Type of Industry (or SIC code if known)

2-50

Census
Current benefits highlight sheet
Renewal
Most recent prior carrier billing

51

Census
Current benefits highlight sheet
Renewal
Most recent prior carrier billing
2 yrs worth of loss ratio (if applicable)

Vision

10-50 or 500 Total Eligible Lives

State
Rate Tiers 2, 3 or 4 tier
Voluntary - Employer pays less than 25%
Non-Voluntary - Employer pays greater than 80%
or bundled with Medical/Dental
Mixed - Employer pays between 25% and 80%

Ancillary Lines

Group Life
Group AD&D
Group STD / LTD
Group Dental
Group Supplemental Life
Group Dependent Life
Voluntary Dependent Life
Voluntary STD / LTD
Voluntary Dental

2-99 lives

Census

Date of Birth
Benefit amount
Gender
Occupation
Salary & salary mode
Class
Dental tier & zipcode
Copy of current benefit book or contract plan design
Current rates
Employer contribution for employees (and dependents)

100 lives
Census

Date of Birth
Gender
Benefit amount
Occupation
Salary & salary mode
Class
Dental tier & zipcode
Copy of current benefit book or contact and plan design
Current rates
Employer contribution for employees (and dependents)
Premium & rate history for the last 3-5 yrs
Paid claims history for the last 3-5 yrs
Benefit changes in the last 3-5 yrs

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