CMA Quote Request Form

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I'm interested in receiving quotations and more information about the following sponsored insurance programs!

To receive more information and a quote on any of the medical association sponsored insurance programs, please complete Sections I and II. Groups should also complete Section III. You may also fax this information to Marsh Affinity Group Services at 213-346-5946, or call us at (800) 842-3761.

Please note that this form is only a request for quotations and not an application for insurance.

Section I This section is required to receive information about the Sponsored Insurance Programs
Which County Medical Association/Society do you belong to?
Physician Name
Practice Name
Address
Suite/Apt
City
State
Zip
Phone
Fax
E-mail Address
Contact Name

Section II
Medical Programs (Groups must complete Section III)
Member's Date of Birth
Residence Zip Code
Who is Covered?	Self Self and Spouse Self, Spouse and Child(ren)
Choose your plan type:
From which Health Plan would you like a quote:

Dental Program Underwritten by The Guardian – Groups must complete Section III
Preferred Provider Organization	Physician Only Physician and Employee(s) Employee(s) Only

Long Term Disability Underwritten by Hartford Life Insurance Company
Member's Date of Birth
Monthly Benefit Desired (up to $10,000/month under age 50. $6,000/month ages 50–54)	$
Benefit Period	Basic (Injury to age 65, or 5 year sickness) Extended (Injury and sickness to age 65)
Waiting Periods	90 Days 120 Days 180 Days
Options	Recovery Benefits COLA

Business Overhead Expense Underwritten by Hartford Life Insurance Company
Member's Date of Birth
Monthly Benefit Desired (up to $15,000/month)	$

Term Life Insurance Underwritten by Hartford Life Insurance Company
Member's Date of Birth
Life Insurance Desired for Member (increments of $25,000 to a maximum of $1,000,000)	$
Spouse's Date of Birth
Life Insurance Desired for Spouse (increments of $25,000 to a maximum of $500,000)	$

Group Universal Life Insurance Underwritten by Metropolitan Life Insurance Company
Member's Date of Birth
Life Insurance Desired for Member (increments of $25,000 to a maximum of $1,000,000)	$
Spouse's Date of Birth
Life Insurance Desired for Spouse (increments of $25,000 to a maximum of $500,000)	$

Workers' Compensation Underwritten by Fireman's Fund Insurance Company
Annual Employee Payroll	$
Number of Employees
Name of Present Workers' Compensation Carrier
Current policy expiration date
Address of additional office locations, if any
Do you fly an aircraft for business purposes?	Yes No
Have you ever been canceled by any Workers' Compensation carrier?	Yes No
If incorporated, do you wish coverage for yourself?	Yes No
Medical Specialty
Social Security or Tax ID Number
Is the sum of these operations less than 25% of your total office payroll?	Urgent Care Physical Therapy Blood Donor/Drawing Center Non-Profit Pregnancy Termination Clinics Yes No
Business type	Individual Partnership Corporation
If your business is a partnership or corporation, complete these questions
Partnership/Corporation Name
Title
% of Stock Owned
Are the officers/partners to be covered?	Yes No

Employment Practices Liability Program
Limits of coverage desired	$250,000 per claim/$250,000 aggregate $500,000 per claim/$500,000 aggregate $1,000,000 per claim/$1,000,000 aggregate
Number of employees
Do you currently have a stand alone EPLI policy?	Yes No
In the last 5 years, have you had any EPLI claims or any known situations that could give rise to a claim?	Yes No

Long Term Care Program Underwritten by Metropolitan Life Insurance Company and John Hancock Life Insurance Company
Member's Date of Birth
Long Term Care Facility Monthly Benefit
Elimination Period	30 Days 90 Days 180 Days
Benefit Duration
Options
Coverage For:	Self Spouse Parent Grandparent

Accidental Death & Dismemberment Underwritten by Unum Life Insurance Company of America
Member's Date of Birth
Death Benefit (up to $750,000 in increments of $50,000)	$
Family Coverage	Yes No

Section III (Groups Only)
Group Name
Administrator Name
Employee Census (name, age, dependent coverage and residence Zip Code)


Page last updated 1/26/07 © 2007 Seabury & Smith Insurance Program Management CA License #0633005