Proposal Request | PSET Insurance

A. Client Information

Client is : *

New

Existing groups please contact PSET directly for changes to current policy. Contact: Marv@profbci.com for more information.

Legal name of group : *

Tax Entity : (check one) *

S-Corp - Form 1120S
C-Corp - Form 1120
Sole Proprietor - Schedule C
Partnership - Form 1065

Physical Address : *

City : *

State : *

Zip : *

Does this group have current / prior policy ? : *

Yes
No

If yes, please provide copy of most current policy.

Current Rate : ($) *

Renewal Rate : (If Any) ($) *

Requested Effective Date : *

Policy Anniversary will be Mar. 1st

B. Plan Will Cover: Please fill in class description

Class I : *

Class II : *

Class III : *

C. Long term disability insurance

Coverage Level : (check one) *

60%
66.67%
Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Monthly Benefit Max : (check one) *

$6K
$8K
$10K
Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Elimination Period : (check one) *

30 Days
90 Days
180 Days
Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Benefit Riders : *

Cost of Living Adjustment (COLA)
Qualified Medical Condition (QMC) (Physicians Only)
Own Specialty
Assisted Living Benefit (ALB) @ 80%
Assisted Living Benefit (ALB) @ 100%
Lifetime Security Benefit (LSB)
24 Mo Return to Work (Increase From 12 Mo)
24 Mos Survivor Benefit (Increase From 3 Mo)
Childcare Benefit

D. Short Term Disability Income Insurance

Include in quote ? *

Yes

Weekly Benefit Max : *

$1,000
$1,500
Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Max Benefit Duration : (check one) *

13 Weeks
26 Weeks
Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Elimination Period : *

7 Days For Sickness And 0 Days For Accident
14 Days For Sickness And 14 Days For Accident
Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

E. Life Insurance and Accidental Death and Dismemberment

Include in quote ? *

Yes

Annual Earnings : *

1 x Earnings $50,000
1 x Earnings $400,000
2 x Earnings $400,000
3 x Earnings $400,000
Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

F. Employer Contribution

Employer Contribution : *

Contributory (Employee will pay some portion of the premium)
Non-Contributory (Employer will pay 100% of premiums with no cost to employee)

If Non-Contributory : *

Premium Included : Premiums will be reported on W2 and benefits will be non-taxable
Premium Excluded : Premiums will not be reported on W2 and benefits will be taxed

G. Additional Notes / Requests:

*

H. Signature & Census Form

Broker Signature : *

By checking this box, I certify that the information on this RFP is complete and accurate.

Signature Date : *

Upload completed Census Document : *

Census information must be submitted with this RFP. Please download, complete form as accurately as possible, and upload below.