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*Quote Type:

"Standard quote" (24-hour turnaround) — This is a shelf quote for groups that do not require underwriting pre-approval.

"Nonstandard or groups of 500+ quote" (3-5 business day turnaround) — Cases that require underwriting pre-approval.

group information

* First Name:
* Last Name:
* Email:

Proposed Effective Date:
* Company:
Company Address:

Situs City:
Situs State:

Company Phone:
Conseco Rep:

* Nature of business:
Industry:
SIC code:

Group has disability coverage?
Definition of eligibility:

hours full-time

Number of eligible employees:

STD Eligible Classes

Class 1:

Class 2:

PLANS REQUESTED (Subject to state requirements)

class 1

Plan 1

Plan 2

Type:
13 wks:
26 wks:
52 wks:
104 wks:

class 2

Plan 1

Plan 2

Type:
13 wks:
26 wks:
52 wks:
104 wks:

Additional notes:

Additional items needed for quoting on groups with 500+ eligible employees:

Census: gender, DOB, occupation, date-of-hire, class indicator, salary, work location (zip or state) (For takeover, include enrolled employee indicator or most recent copy of prior carrier’s bill.)
Historical turnover information and lives history
Enrollment strategy
Inforce plan design (booklet/contract or summary plan design) (For takeover only)
Paid premiums and paid claims for the past 3 years, broken out by month (preferable) or year
Current eligibility and inforce rates (For takeover only)
Rate, plan and lives history (For takeover only)
Effective date of coverage with current carrier

takeover

Is takeover requested?

If yes, name of current carrier:

Does the group have a sick leave or PTO/PPT plan?

Conseco Health Insurance Company is licensed in all states except CT, MA and NY. Conseco Insurance Company is licensed in all states except NY.

Conseco Worksite is a dedicated sales division of the Conseco insurance companies specializing in workplace-related insurance products. All products mentioned on this Web site are issued and underwritten by the Conseco Health Insurance Company and Conseco Insurance Company, a life and health insurance company.

This Web site should be considered an advertisement and is not a contract. Products and services mentioned in this Web site are only valid for distribution in the United States of America and may not be available in all states.

An agent will contact you.

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