Northwest Benefits Group





Our Carriers

Answer 1:  

INSIDE OREGON

Answer 2:  

GROUP PLAN

For an accurate quote, please fill in all fields. Areas marked in bold are required fields. Please note the use of the following abbreviations for the CATEGORY fields throughout the form: EE = Employee; EE/SP = Employee/Spouse; EE/FAM = Employee/Family; EE/CH = Employee/Child(ren).
  Contact Info
Name of Business  
Proposed Effective Date  
Contact Person  
Contact Phone  
Contact Fax  
Contact Email  
Address  
City  
Zip  
Nature of Business  
Years in Business  
Present Carrier  
Effective Date  
Employer Contribution   EE   %   Dependent   %   Probationary Period  
Current Plan Description  
Rates Medical Dental Vision Life Disability
      Yes No Yes No   Yes No
Employee   
Employee + Spouse  Short-term
Employee + Family  Long-Term
Employee + Child(ren)     

Census
Quotes require that you fill-out this census form. Please list all employees. A minimum of 2 employees is required for a Group quote.
Employee 1 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 2 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 3 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 4 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 5 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 6 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 7 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 8 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 9 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code
Employee 10 Name Date of Hire Currently Covered

Y     N		 Sex

M     F
Date of Birth Use Tobacco

Y     N		 Enrollment Status Employee ZIP Code

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