Quote Form | Group Benefits

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189 Route 100, PO Box 590

Somers, NY 10589

Westchester County, NY

Toll Free: 1-800-498-1819

Office: (914) 276-6000

Fax: (914) 401-9319

info@directaccessgroupbenefits.com

First Name

Last Name

Company

Phone

Preferred Method of Contact:

Phone

Federal Employer's ID #

Description of Operations:

Group Health Insurance

Please fill out the section below that applies to you.

Any Employees Currently Insured:

Yes

Who will be insured:

Number of Employees to be Insured:

Choose coverage:

HMO Group Health Insurance

PPO Group Health Insurance

POS Group Health Insurance

Major Medical Health Insurance

HMO Co-Pay Amount Desired:

PPO Deductible Amount Desired:

POS Co-Pay Amount Desired:

Major Medical Deductible Desired:

Choose Additional Benefit Options

Dental

Vision

Life & Disability

Has the employee to be insured experienced any health problems in the past 18 months?

If Yes, please list employee(s) information:

Group Life & Disability

Currently Insured:

Insurance Expiration Date:

Any losses past 3 years?

Description of losses, including amount paid on each accident

Who will be insured:

Amount of Life Coverage Per Employee:

Length of Group Disability Coverage Needed:

Type of Group Disability Coverage Needed:

Monthly Benefit Amount For Each Person Insured:

Benefit Period Desired For Each Person Insured:

Elimination Period Desired For Each Person Insured:

Payment Mode:

Has anyone to be insured had health problems during the past 3 years:

If Yes, please list information:

Anyone to be insured have a hazardous job:

If Yes, how many with hazardous jobs:

Anyone to be insured an active member of the military reserves:

If Yes, how many are members of the military reserves:

Questions?

Message:

By submitting this request, you confirm your understanding that it does not constitute an offer of insurance or a guarantee of coverage.

Thank you for submitting! We will be in touch with you soon.

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