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.
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This section is required to receive information about the Sponsored Insurance Programs |
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Which County Medical Association/Society do you belong to?
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Physician Name
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Practice Name
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Address
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Suite/Apt
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City
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State
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Zip
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Phone
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Fax
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E-mail Address
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Contact Name
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(Groups must complete Section III) |
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Member's Date of Birth
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Residence Zip Code
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Who is Covered?
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Self Self and Spouse Self, Spouse and Child(ren) |
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Choose your plan type:
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From which Health Plan would you like a quote:
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Underwritten by The Guardian – Groups must complete Section III |
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Preferred Provider Organization
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Physician Only Physician and Employee(s) Employee(s) Only |
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Member's Date of Birth
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Monthly Benefit Desired
(up to $10,000/month under age 50. $6,000/month ages 50–54) |
$ |
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Benefit Period
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Basic (Injury to age 65, or 5 year sickness) Extended (Injury and sickness to age 65) |
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Waiting Periods
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90 Days 120 Days 180 Days |
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Options
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Recovery Benefits COLA |
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Member's Date of Birth
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Monthly Benefit Desired
(up to $15,000/month) |
$ |
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Member's Date of Birth
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Life Insurance Desired for Member
(increments of $25,000 to a maximum of $1,000,000) |
$ |
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Spouse's Date of Birth
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Life Insurance Desired for Spouse
(increments of $25,000 to a maximum of $500,000) |
$ |
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Underwritten by Metropolitan Life Insurance Company |
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Member's Date of Birth
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Life Insurance Desired for Member
(increments of $25,000 to a maximum of $1,000,000) |
$ |
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Spouse's Date of Birth
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Life Insurance Desired for Spouse
(increments of $25,000 to a maximum of $500,000) |
$ |
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Annual Employee Payroll
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$ |
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Number of Employees
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Name of Present Workers' Compensation Carrier
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Current policy expiration date
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Address of additional office locations, if any
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Do you fly an aircraft for business purposes?
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Yes No |
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Have you ever been canceled by any
Workers' Compensation carrier? |
Yes No |
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If incorporated, do you wish coverage for yourself?
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Yes No |
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Medical Specialty
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Social Security or Tax ID Number
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Is the sum of these operations less than 20% of your total office payroll?
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Urgent Care Physical Therapy Blood Donor/Drawing Center Non-Profit Pregnancy Termination Clinics Yes No |
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Business type
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Individual Partnership Corporation |
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Partnership/Corporation Name
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Title
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% of Stock Owned
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Are the officers/partners to be covered?
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Yes No |
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Underwritten by Fireman's Fund |
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Equipment Protection Amount
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$ |
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Equipment Protection Options
(check options desired) |
Inflation Fighter Beeper Coverage Cellular Phone Coverage |
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Business Interruption and Extra Expense
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$ |
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Protection Amount
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$ |
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Accounts Receivable Amount
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$ |
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Records & Valuable Papers Protection
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$ |
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Data Processing Equipment
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$ |
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Data Processing Media
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$ |
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Underwritten by Unum Life Insurance Company of America |
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Member's Date of Birth
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Long Term Care Facility Monthly Benefit
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Elimination Period
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30 Days 90 Days 180 Days |
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Benefit Duration
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Options
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Coverage For:
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Self Spouse Parent Grandparent |
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Underwritten by Unum Life Insurance Company of America |
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Member's Date of Birth
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Death Benefit
(up to $750,000 in increments of $50,000) |
$ |
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Family Coverage
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Yes No |
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(Groups Only) |
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Group Name
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Administrator Name
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Employee Census
(name, age, dependent coverage and residence Zip Code) |
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| Page last updated 3/23/04
© 2004 Marsh Affinity Group Services |
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