the Amwell agency
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Life
Insurance
Fixed
Annuities
Eliminate
Debt
Financing
Employee
Benefits
Disability
Insurance
Long Term
Care
Saving for
College?
Affiliates
Bio
Contact
Employee Benefits Proposal Request
Company Name
Zip Code
Contact Name
Contact Phone
Fax
Do you have a current plan?
Yes
No
Next renewal date
Health Plan Options Requested
Type
-- select --
HMO
POS
PPO
Co-Pay
-- select --
$20
$25
$30
Deductible
-- select --
$500
$1,000
$2,500
Co-Insurance (if applicable)
-- select --
80/20
70/30
60/40
50/50
Hosptial Co-Pay (if applicable)
-- select --
$250
$300
$500
$750
Note, 5 night max per illness, then cover 100%
Stop Loss
-- select --
$5,000
$10,000
Employee Name
Sex
Birth Date
Status
Job Title
Home Zip
1
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
2
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
3
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
4
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
5
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
6
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
7
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
8
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
9
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
10
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
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