NCIA Insurance Request for Proposal

REQUEST FOR A PROPOSAL

Broker:		Phone Number:
Broker email:		Fax Number:
Group Name:
Street Address:		Effective Date:
City, State, Zip:		Lives:
Employer Contribution:		Nature of Business/SIC code:

Voluntary Life	Voluntary AD&D	Voluntary STD
Voluntary LTD	Voluntary Dental

NOTE: SIC Code or nature of business needed to quote Vol Life, STD and LTD

GROUP LIFE/AD&D
Flat Amount for all eligible employees: (select desired option(s)):
	$10,000	$15,000	$20,000	$25,000
	$30,000	$35,000	$40,000	$45,000
	$50,000	$75,000	Other: $

X Base Annual Earnings to a maximum of: $

(rounded to the next higher $1,000)

Benefits by job title with at least one employee in each class

*Class Description*		*Amount*
I.		$.
II.		$.
III.		$.

Age Reduction Schedule - Life and AD&D reduce by 35% at the age of 65 and further reduce to 50% of the
original amount at the age of 70. Benefits terminate at retirement. This is the standard age reduction.

SPECIAL AGE REDUCTION - Benefits reduce by % at age and further reduce by
% at the age of .

Current Carrier: Current Rates$: per $1,000

SHORT TERM DISABILITY
Benefit Duration	13 wks	26 wks	52 wks	Other:
Benefit Begin - Accident	1st day	8th day	15th day	Other:
Benefit Begin - Sickness	1st day	8th day	15th day	Other:
Benefit Begin - Hospital	1st day - Yes		No
Benefit Amount	50%	60%	66 2/3%	Other:
	of weekly income to a max of $

Flat amount of $. not to exceed 66 2/3% of weekly income.

Current Carrier: Current Rates $: per $10

*CHECK IF YOU WISH TO HAVE THE FOLLOWING PRODUCTS QUOTED*
*LTD*	*DEPENDENT LIFE*	*RETIREE COVERAGE*

DEPENDENT LIFE
Plan I	Plan II
Spouse Benefit - $5,000	Spouse Benefit - $2,000
Children - birth to 6 months - $100	Children - birth to 6 months - $100
Children - 6 months to 21 years - $2,000	Children - 6 months to 21 years - $1,000

	Plan III CUSTOM
	Spouse Benefit - $
	Children - birth to 6 months - $
	Children - 6 months to 21 years - $
	(Children may be covered to age 23 if full-time student)

Current Carrier: Current Rate $: per $1,000 or $ per unit

LTD
Elimination Period:	90 Days	180 Days	360 Days	Other:
Benefit Percentage:	50%	60%	66 2/3%	Other:
Maximum Monthly Benefit:	$3,000	$5,000	$6,000	Other:
Benefit Duration:	RBD	65/5/70	T70	Other:
Definition of Disability:	24 MO. Own Occ	36 MO. Own Occ		Other:
Number of Years in Business (MUST BE MORE THAN 2 YEARS)
Number of Lives:

Current Carrier: Current Rate(s) $: per $100

RETIREE COVERAGE
	Description	Amount
Grandfathered Retirees:		$
Future Retirees:		$

200 LIVES OR MORE

The following information MUST be submitted in order to obtain a quote UNLESS the company has NEVER had Life coverage perviously.

Last three years of paid primium and claims history.
Rate history for the previous three years.
A complete list of insured employees on approved waiver of premium, including benefit amount and date of leave.
A complete list of open claims, including claimant's date of birth, date of leave/disability, net monthly benefit and occupation.
Copy of current plan booklet or contract.

FOR ASSISTANCE CONTACT:

New Group Account Service Rep.
(202)680-7077

840 1st St., NE
Washington, DC 20065
FAX (202)680-7644