Get a Quote - Group Health/Life/Disability
 

Please enter the following information and click "Submit Quote Request" at bottom.

Basic Information  
Business Name:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone:
Fax:
Nature of Business:
Contact Person:
Email Address:
   
Life and AD & D Coverage
Number of Employees:
Number Eligible:
Current Carrier:
Renewal Date:
Current Rate:
Renewal Rate:
Amount of Death Benefit:
Flat Amount:
Multiple of Earnings:
Schedule:
Employee Census information including Date of Birth, Sex and Job Title/Earnings or coverage comments will be required. Loss Information will be helpful and may be required on groups over 100 lives.
Describe any Pre-existing Health Conditions:
Note any other pertinent information or requests for coverage:
   
Group Health Coverage
Number of Employees:
Number Eligible:
Current Plan: HMO

POS

PPO

Indemnity
Plan to Quote: HMO

POS

PPO

Indemnity
Desired:
Deductible:
Co-Pay:
Co-Insurance:
Describe any Pre-existing Health Conditions:
Note any other pertinent information or requests for coverage:
Employee Census information including Date of Birth, Sex , Location and Family status will be required. Loss information, including shock loss, will be helpful, and may be required for groups over 100 lives.
   
Group Dental Coverage
Number of Employees:
Number Eligible:
  Deductible Co-Insurance
Class A:    
Class B:    
Class C:    
Calendar Year Maximum:  
Orthodontia: Yes No Children under age 19
Describe any Pre-existing Health Conditions:
Note any other pertinent information or requests for coverage:
   
Group Disability Coverage
Number of Employees:
Number Eligible:
Coverages Desired: STD LTD
Current Carrier:
Renewal Date:
Current Rates: STD:  LTD:
Renewal Rates: STD:  LTD:
Benefits to be Quoted:
  STD LTD
Elimination Period:    
Percentage Payable:    
Maximum Benefit:    
Duration Benefits:    
Employee Census information including Date of Birth, Sex, Job Title and Earnings will be required. Loss Information will be helpful and may be required on groups over 100 lives.
Describe any Pre-existing Health Conditions:
Note any other pertinent information or requests for coverage:
   

 

 

 
Franklin Insurance

104 13th Street
Franklin, PA 16323
(814) 432-4523 - (800) 346-8714
(814) 432-8644 (fax)

  Titusville Insurance

314 South Franklin Street, Suite D-1
Titusville, PA 16354
(814) 827-8888
(814) 827-3557 (fax)

© 2006 - Franklin Insurance Agency, Inc.