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)

>> Contact Me Directly

General Information

Requested Effective Date for Coverage to Begin

Employer's Legal Name

Billing Address


State & Zip


Mailing Address


State & Zip


Telephone Number

FAX Number

Name/Title of Contact Person

Email Address of Contact Person

Is your company a member of NAMIC?

Yes     No

Eligibility Information

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

Employer Contributions

Group Life/AD&D

% 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

% 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? Yes No

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 *

Fixed Amounts






Salary Option

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:

Supplemental Life

Dependent Life

Supplemental AD&D

Long Term Disability Insruance (LTD)

Elimination Period

90 Days

180 Days

Benefit Schedule



Benefit Payment

$8,000 Monthly Maximum

$10,000 Monthly Maximum



Employee/Shared Payment

Short Term Disability Insruance (STD)

Elimination Period (Sickness/Injury)

7 Days

30 Days

Benefit Period

13 Weeks

26 Weeks

Benefit Schedule


Benefit Payment

$300 Weekly Maximum

$2,000 Weekly Maximum



Employee/Shared Payment

Dental Insurance

Groups can offer both a high and a low dental plan to all employees

High Option

Low Option


Vision Insurance


No Vision

* 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.

Today's Date:

I hereby certify that I have the authority to make this request for my company.

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