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Request a Quote
If you are interested in a quote for insurance coverage through NAMIC Benefit Solutions, please fill out the online form below, or use the PDF fill-in form linked below to submit your request by email, fax or mail.
>> Download/Print Quote Request Form (PDF)
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Requested Effective Date for Coverage to Begin
Employer's Legal Name
State & Zip
Name/Title of Contact Person
Email Address of Contact Person
Is your company a member of NAMIC?
Total Number of Employees on Payroll:
Total Number of Permanent Full Time* Employees:
* Full-Time employees must work a minimum 20 hours per week.
Number of Directors who are not Active Employees:
Number of Employees Currently Enrolled
% Group Life/AD&D
Supplementary Life Insurance
% Supplementary Life Insurance
Supplementary Accidental Death & Dismemberment
% Supplementary Accidental Death & Dismemberment
Long Term Disability
% Long Term Disability
Short Term Disability
% Short Term Disability
Dental Insurance High Plan Low Plan
% Dental Insurance
% Vision Insurance
Benefits waiting period for new employees is the completion of:
30 Days 60 Days 90 Days 180 Days 365 Days
Are any former employees and/or dependents eligible for coverage through COBRA for dental or vision?
If yes, please identify by name.
To the best of your knowledge, are any employees or dependents proposed for coverage disabled or unable to work because of a current or approaching hospital confinement, leave of absence or otherwise incapacitated? Yes No
If yes, please provide the person's name and current status.
Please indicate all options below for which you would like a quote(s):
Group Life/AD&D Insurance *
1 X Salary
1.5 X Salary
2 X Salary
2.5 X Salary
3 X Salary
*Employers must pay 100% of the premium to be eligible for pricing quoted.
Supplementary Life Options
These products may be either employer paid or employer/employee shared payment:
Long Term Disability Insruance (LTD)
$8,000 Monthly Maximum
$10,000 Monthly Maximum
Short Term Disability Insruance (STD)
Elimination Period (Sickness/Injury)
$300 Weekly Maximum
$2,000 Weekly Maximum
Groups can offer both a high and a low dental plan to all employees
* NAMIC reserves the right to perform employer audits to ensure employers are paying the entire cost of any coverage elected as "100% employer paid".As confirmation of acceptance of quote, please check the appropriate boxes below.
I hereby certify that I have the authority to make this request for my company.
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