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UNDER 50 GROUP ONLINE QUOTE REQUEST

Thanks for visitng The Cason Group Request for Quote page. For each line of coverage please supply all the requested information. Incomplete information will delay us in getting you the most competitive rates for your group! If you have any questions please contact your Marketing Representative or service@thecasongroup.com.
General Information
Agent Information
Agent Name:
Agent Company:
Agent Street: Agent City:
Agent State:
Agent Zip:
Agent Phone:
Agent Fax:
Agent Email:
Preferred
Reply:
 E-mail
US Mail
Facsimile
Group Information
Group
Name:		 City:
Group State: Group Zip:
Other Locations:
Nature of Business:
Effective Date :
Out of State Zips:
Desired Benefits
Life Insurance
Flat Amount:
Classes
Class 1:
Multiple of Salary:
Class 2:
Employer
Contribution:
Class 3:
Takeover: Yes No
Class 4:
Voluntary: Yes No
Medical Insurance
Medical Deductible:
Medical Maternity:
 Yes No
Supplemental Accident:
Medical Drug Card:
 Yes No
Coinsurance %:
PPO:
 Yes No
   
HSA:
 Yes No

Dental Insurance

Employer Contribution:
Dental Max:
Dental Orthodontics:
 Yes No
Takeover:
 Yes No
Voluntary:
 Yes No    

Short Term Disability

Day
duration:
   
Day
accident:
Day
sickness:
Coverage amounts:
%
to
$
  Or flat $
Takeover:
 Yes No      
Employer Contribution:
Voluntary:
 Yes No          

Long Term Disability

Day Elimination Period
%
  to
 $
 
Duration:
    
Own Occupation:
 
Takeover:
 Yes No    
Employer Contribution:
 
Voluntary:
 Yes No          
 
Notes:
    
EMPLOYEE CENSUS INFORMATION
Please complete one row for each employee:
Last Name First Name DOB/Age Sex Spouse Age # Of
Children		 Occupation
(If App.)		 Classes
(If App.)		 Salary
(If App.)
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Copyright ® 2005 The Cason Group

 

Authorized Agent for BlueChoice HealthPlan and BlueCross BlueShield of South Carolina.

BlueChoice HealthPlan is a wholly owned subsidiary of BlueCross BlueShield of South Carolina. Both are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. "BlueCross", "BlueShield" and "BlueChoice" are registered marks of the Blue Cross and Blue Shield Association