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HΔMMURΔBI
Hey, I'm Amber
Answer The Questions Below To Get Started
Account Information
(Step 1/6)
Account Name:
Select Option
YES
NO
Is Business Renewal:
Account Address 1:
Account Federal Id:
Account Zip:
Effective Date:
Expiration Date:
Select a State
Account State:
Account Address 2:
SIC:
Next
Account Information:
(Step 2/6)
Months In Contract:
Written Census:
Total Lives
Sp Deductible:
Select Option
12/12
12/18
12/24
24/12
18/12
Paid
Sp Contract:
SIC Description:
Select Option
Yes
No
Sp Agg Deductible:
Is Fully Insured:
Is Self Funded:
Is Level Funded:
Account Information:
(Step 3/6)
Ag Contract Type:
Ag Gross Collected Premium:
Producer Name:
Producer License:
Producer State:
Claim Administrator Name:
Policy Status:
Is Claim Self Administered:
Underlying Benefit PlanName:
Census List:
(Step 4/6)
Enrollee Count:
Enrollee Covered:
Total Lives Covered:
Select Option
YES
NO
Is Retired:
Select Option
YES
NO
Is COBRA:
Zip Code:
Select Option
YES
NO
Is Medical Coverage:
Select Option
YES
NO
Is Rx Card Coverage:
Select Option
YES
NO
Is Dental Coverage:
Select Option
YES
NO
Is Vision Coverage:
Census List :
(Step 5/6)
Select Option
YES
NO
Is Weekly Income Coverage:
Select Option
YES
NO
Is Life Coverage:
Select Option
YES
NO
Is Life Coverage:
Select Option
YES
NO
Is ADD Coverage:
Life Coverage:
Opt Life Certificate:
Group No:
Select Option
YES
NO
Is Included In Quote:
Census list:
(Step 6/6)
Is Primary ICD Code:
Select Option
YES
NO
Is Included In Quote:
Life Class No:
Is Large Claimant:
