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                                     What It Means to Be a CIC - The Certified Insurance Counselor (CIC) designation is a distinction that represents a commitment to professional excellence and leadership within the insurance industry. The 28,000+ designated CICs across the country are recognized as among the best and most knowledgeable insurance practitioners in the nation. The formal training required to become a CIC includes 100 classroom hours and the successful completion of five comprehensive exams, with an annual update required to ensure that CICs maintain their edge as the most capable and current insurance practitioners in the industry.

We've Made Shopping For Group Health / Life / Dental / Vision Insurance Coverage Fast, Easy, and Available Online

To Get A Quick Group Health Insurance Quote With Several Leading Insurance Companies Complete A Short Online Information  Form

 
* Company Name                * Your Name  
 * Telephone           * Email Address   
* Fax           * Best Time To Call   
* Address         

* City * Number Of Employees

* State         

* Zip                         * Number On Group Plan

 * List SIC Code or Briefly Describe Business Operations

 Current Health Insurance:   If Other Specify  Renewal Date:

Comments:

 

  Click On Any Of The Selected PPO or HMO Benefits Options Your Firm Would Like To Consider:    

Cal. Year Deductible

Per Covered Individual

Applies To Covered Major Medical & Hospital Expenses Before Benefit Start

(Note Major Medical Expense Deductible Does Not Apply Where Co-payments Are Applicable)

 

Coinsurance  Payment

Percentage Of In-Network Charges Your Insurance Plan Will Pay Before Covered Expenses Out-Of-Pocket Maximum Applies

 

Maximum

Out-Of-Pocket

Maximum Dollar Amount of Coinsurance Payment You Pay Before Your Plan Pays 100% Of Covered Expenses

(Note Deductible Is Not Included In This Amount - Total Out-Of-Pocket Expenses  = Ded. + Max OP Co-ins.)

Physician Office Visits

Co-Payment

 You Pay Co-Payment To Physician - Then Plan Pays 100% Of Covered Expenses

(Note Major Medical Expense Deductible Does Not Apply Where  Co-payments Are Applicable)

    Prescription Drug

 Co-Payment

You Pay Co-Payment To Pharmacy - Then Plan Pays 100% Of Covered Expenses

(Note Major Medical Expense Deductible Does Not Apply Where  Co-payments Are Applicable)

 $     250 100 %                              ( no co-insurance applies) $  1,000 $  10

$10 Generic         

$ 20 Brand 
$ 30 Non-Formulary
 $     500   90 % $  2,000 $  15

$15 Generic         

$ 30 Brand 
$ 60 Non-Formulary
 $  1,000   80 % (industry standard) $  3,000 $  20

$20 Generic         

$ 40 Brand 
$ 80 Non-Formulary
 $  2,000   75 % $  4,000 $  30 $  No 1st $ Rx Plan Applies  - HSA Plans Only
 $  5,000 HSA Plans   70 % $  5,000 HSA Plans $  40
 $10,000 HSA Plans  50 % $10,000 HSA Plans No 1st $ Co-payment  Benefit Applies - HSA Plans Only
Other Insurance Benefits Requested: Life Dental Vision Short Term ( 26 Wks) Disability Income Long-Term (To Age 65) Disability Income

 Do you already have a group census that you would prefer to fax or email us? Yes No

If yes please fax to:  936-448-1013 or email  to : edhemphill@hemphillinsuranceagency.com ; please be sure to click the submit button at bottom of this form before you exit this web page (Please skip completion of online census form shown below ) .

 

Does your firm currently employ 51 or more employees ? Yes No

If " Yes " our  insurance counselor will contract you to discuss your current carriers benefit plan , claims experience   ( loss history ) , and type employee benefit plans you would like to consider . Click submit button at bottom of this form ( Please skip completion of online employee group census form shown below ) .

Employee Group Census

Please provide the following information for each employee to be insured.

Employee Name Age Sex Home Zip Coverage Type #/Children            ( provide # only if children   coverage requested) 
 1. M   F
 2. M   F
3. M   F
4. M   F
5. M   F
6. M   F
7. M   F
8. M   F
9. M   F
10. M   F
11. M   F
12. M   F
13. M   F
14. M   F
15. M   F
16. M   F
17. M   F
18. M   F
19. M   F
20. M   F
21. M   F
22. M   F
23. M   F
24. M   F
25. M   F
26. M   F
27. M   F
28. M   F
29. M   F
30. M   F
31. M   F
32. M   F
33. M   F
34. M   F
35. M   F
36. M   F
37. M   F
38. M   F
39. M   F
40. M   F
41. M   F
42. M   F
43. M   F
44. M   F
45. M   F
46. M   F
47. M   F
48. M   F
49. M   F
50. M   F
Submitting Agent/ Producer  - Name: Tel: Email: