Forms for Brokers

Census 2 - 50
This spreadsheet lists the Employee Name, Gender, Date of Birth, Marital Status and Home Zip Codes. This information is required when quoting companies with over 50 employees, out of New York State companies and companies with out of state Employees.

Census 50+
This spreadsheet also lists the Employee Name, Gender, Date of Birth, Marital Status and Home Zip Codes. This form is a continuation for companies who have over 50+ employees, companies out of New York State companies and companies with out of state Employees.

Census Life and Disability
This spreadsheet lists the Employee Name, Gender, Date of Birth, Marital Status and Home Zip Codes. This information is required when quoting Life and Disability Insurance.

Detailed Group Referral - Current Information
This form details a clientís current group health insurance information. With this information, we are able research the market for competitive plans and rates.

Detailed Group Referral - Plan Interested In
This form details the plan design the clients are interested in. With this information, we are able to custom-tailor a plan that meets our clientsí group insurance requests.

Group Referral Form
This is the standard Group Referral Form that we use to gather information about our clients, their current plans and the plans that they are looking to purchase. This form is simple and does not go into as much detail as the Detailed Group Referral forms do. Please put your name, email address and phone number on the top of the form. Fill out as much information as you can. We require the company name, zip code and census in order to calculate accurate quotes.

Multi State & Subsidiary Addresses
Many clients we come in contact with have multi state locations as in having a New York main office and offices in other states or subsidiaries in various locations that they would like to cover under their Group Insurance plan. In this case, we ask that you have your client complete this form so we may quote the necessary companies. If your client has employees or companies outside of New York State, please ask them to complete a Census form along with this one for their main location, its other offices or subsidiaries.

Physician Survey Report
This spreadsheet asks that your client complete the Physicianís Name, Phone Number, City State and Zip Code and Specialty. This information is requested in order to ensure that your clientsí doctors and hospitals will be covered within the health insurance plans we quote for them.

Prescriptions
This worksheet asks that you complete the name of your prescription and what it is used to treat. This information is requested in order to ensure that your clientsí prescriptions will be covered within the health insurance plans we quote for them. We will then complete the last column and inform your clients as to what tier structure their prescriptions will be covered under and at what cost.