/ Quote Request Checklist (50+)
GROUP AND EMPLOYEE CENSUS INFORMATION REQUIRED (Please provide census information using the iSelect Excel template)
Today’s date: / Effective date: / Renewal Date:
Group name:
Description of business: / SIC Code:
Group’s full address: / County:
Does the Group have multiple locations? Yes No If so, provide address for each location below
# of FT Equivalent employees: / # of benefit eligible employees: / # of participating: / # of waivers: / COBRA enrollment:
Current carrier: / Years with current carrier: / Group number:
AGENT INFORMATION
Agent name: / Agency name: / Are you the AOR: Yes: No:
Phone: / Email address:

Note: HAP requires non-standard requests in writing. The letter must be on agency letterhead and be signed by an agency principal.

INFORMATION REQUIRED
Union? Yes No Name of Union: / Employer contribution level:Single% or $ Family% or $
Claims experience: Most current 24 months of claim experience (and premium) with corresponding monthly enrollment. Current carrier’s renewal exhibit with claims data included is adequate.
Large Claims Report for individuals with >$10,000 in claims, including diagnosis and prognosis and amount paid.
Medical benefitsfrom current carrier
Medical ratesfrom current carrier
Renewal rates from current carrier / For theAncillary Rates, please refer to the second page of this document for specific carrier underwriting requirements.
(Attach checklist)
Designate commission amount: / Note: HAP requires non-standard commission requests in writing. The letter must be on agency letterhead and be signed by an agency principal.
ADDITIONAL INFORMATION REQUIRED FOR SELF-FUNDED GROUPS
Aggregate Level (i.e. 120%): / Contract Type (i.e. Paid, 24/12, 15/12): / Administration Fees:
COBRA Equivalent Rates: Single $ Double $ Family $
Specific Stop Loss Level (i.e. $25,000): / Aggregate Stop Loss Fees: Single $ Family $ / Specific Stop Loss Fees: Single $ Family $

Additional items may be required after review of the group

Please contact iSelect Agent support if you have any additional questions at (877) 683-6945 or email

Large Group Definition / Carriers / Census / Salary & Commission (Standard Earnings) / Occupation for Each Member / Copy of Current Plan Certificate/Booklets / Current Rates / Current renewal Rates and Last 2 Years of renewal rates / Claims Experience / STD – Premium vs. Claims bs # Enrolled month by month for 36 months (at least 12) / Current Elections for members & Dependents / Confirm Commission Schedule by Line of Coverage for dental, STD & Life
200+ / MetLife:
Den, Vis, STD, LTD, V Life, Crit Ill, Acc, Hosp Indem / X / X / X / X / X / X / X / X / X / X
Guardian:
Den, Vis, STD, LTD, V Life, Acc / X / X / X / X / X / X / X / X / X / X
150+ / Principal:
Dental, STD, LTD, V Life, CI / X / X / X / X / X / X / X / X / X / X
50+ / Delta Dental / X / X / X / X / Over 100 / X / X

275 E.Big Beaver Rd., Suite 107 | Troy,MI 48083REVISED 10/14/2015