All American Benefits Network
‘A tradition of savings and service’

 

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Chamber Member Services Rate Request

 

It's easy!!!  Simply complete this form and we will go to work for you!

Contact and Employer Information 

* Required Field

*Employer Name

*Contact Person 

*Nature_ of Business

Referred by

*Address1

SIC Code

Address2

*City       

*State*ZIP
*Telephone
FAX
EMail
Current Plan Information
Current Insurance Co.

Renewal Date            

Current Benefits:     Dr. Visits   $                    Hospital   $  

                 Emergency Room   $               Prescription  $

Current Premium:     Individual   $                      Family   $

                            Employee & 1 Dependent (Either spouse or 1 child)  $

Total # of Full-time Employees (30+ hours / including owners) * 

## Number of Full-time Employees waiving coverage *

Total # of employees to be covered. (List employees on form below) *

## Coverage can be waived for the following reasons: 

bullet

Employee is age 65 of older and covered by Medicare OR

bullet

Is covered by spouse's employer plan OR 

bullet

Resides in area outside the network service area OR

bullet

Is on COBRA OR 

bullet

MA Health

Please check any additional benefits you are interested in. 

** Please note: Disability quotations require salaries of each employee.

Dental             Short Term Disability**                      Life

  Long Term Disability**                                                Long Term Care

Employee Census Sheet

* I - Individual  D - Dependent (Spouse or Child)    F - Family

Employee Name

Gender

D.O.B.

MM/DD/YY

Zip Code

 I / D / F*

Salary

Comments

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