Company/Group Name: _____________________________________
Address: _________________________________________________
City: _____________________________________________________
State: ____________________ ZIP Code: _______________________
Coverage Outside CA?: ________________ Virgin Group: Y N
SIC: ___________ or Nature of Business: _______________________
Name: ___________________________________________________
Agency: __________________________________________________
Address: _________________________________________________
City: _____________________________________________________
State: ____________________ ZIP Code: _______________________
License #: ____________________Covered CA Certied: Y N
5-24-19
For more Information N. CA call: (877) 361-7342
For more Information S. CA call: (800) 457-6116
License #0M29112
1 BROKER
2 GROUP
3 COVERAGE
Phone: ________________________ Fax: _______________________
Email: ____________________________________________________
Insurance Lines: ___________________________________________
Dickerson Exec: ___________________________________________
Renewal Date: _____________ Eective Date:___________________
Current Medical Carrier: _____________________________________
Current Premium: $ ________________________________________
Current Dental Carrier: _____________________________________
Current Dental Premium: $ __________________________________
Life Amount: $ _________________________
Medical: HMO PPO EPO
Dental
Vision
Life
Employer Contribution: EE % DEP %
STD
LTD
ACC
AD&D
CI
Chiro
Acupuncture
Hospitalization
Workers’ Comp
4 SPECIAL INSTRUCTIONS
Mail Email Fax Pick-up
One of the advantages of working with Dickerson Insurance Services —
we can manage the entire quoting process for you. Its easy to get started.
PROPOSAL REQUEST
Payroll
Electronic Enrollment
ERISA
HSA
HRA
Self-Funded
GAP
MEC/MVP
5 SUBMIT COMPLETED FORM & CENSUS
Via email: quotes@dickerson-group.com
Via fax Southern CA: (323) 805-2905
Via fax Northern CA: (888) 360-7342
www.thebrokersga.com
First Name, Last Name
DOB
mm/dd/yyyy
Age
Medical
Status
Dental
Status
Vision
Status
ZIP Code
for EE
M/F
COBRA
Y/N
Salary***
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Account Executive: _________________________________________
Company/Group Name: _____________________________________
Broker: ___________________________________________________
Email: ____________________________________________________
GROUP CENSUS
Required Medical Status Code (choose 1)
for Employees (EE) for Dependents
EE=Employee Only
ES=Employee/Spouse
EF=Employee/Family
EC=Employee/1 Child, EMC=Employee/Children
SP=Spouse, DP=Dependent
Dental Status Code
(choose 1)
Vision Status Code
(choose 1)
EE, ES, EF
EC, EMC
EE, ES, EF
EC, EMC
***only when quoting LTD, STD and higher amount of Life
1-39
First Name, Last Name
DOB
mm/dd/yyyy
Age
Medical
Status
Dental
Status
Vision
Status
ZIP Code
for EE
M/F
COBRA
Y/N
Salary***
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
Account Executive: _________________________________________
Company/Group Name: _____________________________________
Broker: ___________________________________________________
Email: ____________________________________________________
GROUP CENSUS
Required Medical Status Code (choose 1)
for Employees (EE) for Dependents
EE=Employee Only
ES=Employee/Spouse
EF=Employee/Family
EC=Employee/1 Child, EMC=Employee/Children
SP=Spouse, DP=Dependent
Dental Status Code
(choose 1)
Vision Status Code
(choose 1)
EE, ES, EF
EC, EMC
EE, ES, EF
EC, EMC
***only when quoting LTD, STD and higher amount of Life
40-79
First Name, Last Name
DOB
mm/dd/yyyy
Age
Medical
Status
Dental
Status
Vision
Status
ZIP Code
for EE
M/F
COBRA
Y/N
Salary***
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
Account Executive: _________________________________________
Company/Group Name: _____________________________________
Broker: ___________________________________________________
Email: ____________________________________________________
GROUP CENSUS
Required Medical Status Code (choose 1)
for Employees (EE) for Dependents
EE=Employee Only
ES=Employee/Spouse
EF=Employee/Family
EC=Employee/1 Child, EMC=Employee/Children
SP=Spouse, DP=Dependent
Dental Status Code
(choose 1)
Vision Status Code
(choose 1)
EE, ES, EF
EC, EMC
EE, ES, EF
EC, EMC
***only when quoting LTD, STD and higher amount of Life
80-119