phone: 615.883.7811

Group Medical Quote Request
The following information collected will be used to estimate monthly premiums for Group Medical Coverage.  A final quoted rate is subject to medical underwriting.

Name of Business:

Nature of Business, SIC code if known:

Zip code of Business:



URL address:

Requested Effective Date
(dd/mm/yyyy format)

Number of Full Time Eligible Employees:

Number of Employees Participating in Health Plan
(min. 50% participation required):

Census Information for Participating Employees:
Initial estimates are calculated by the average age and gender of your
group. Final rates are subject to Medical Underwriting.

Group Medical benefit Options
Please select the benefit combination you prefer for your Group Medical
Policy. Please note:  Not all benefit combinations are applicable, Tailored
Business may have to suggest a close alternative, if certain benefit
combinations are no longer available.

1.) Network Selection:

Health Savings Account Eligible:


Out of Pocket Maximum:


Office Visit Copay

Specialist Office Visit Copay:

Pharmaceutical Drug Benefit:

Available Riders:

"Special Accident" - pays $500 of first dollar
medical expenses due to accidental injury:

"Out Patient Surgery Benefit" - pays 100% for all Out Patient Surgery
Procedures. Or this may be left subject to the Deductible and Coinsurance:

"Extended Wellcare" - Covers wellcare visits for adults and children over 6:

"Emergency Room Copay" - You only pay $100 copay when visiting
the Emergency Room, If admitted charges are subject to the Deductible
and Coinsurance:

Group Vision:

Group Dental:

Group Life Insurance:

Group Short Term and Long Term Disability:

Questions or comments:

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