IMA

This form is designed to make sending a request for a proposal as easy as possible. Complete the requested information and check the appropriate boxes, then click on the submit button at the bottom of this page.


Fields marked in BOLD are required

 

Name of Group:
Address of Group:
Industry Type:
Effective Date:
Broker Name:
Broker Phone:
Broker E-mail:
   

Specific Deductible:
$5,000 $10,000 $15,000
$20,000 $25,000 $30,000
$40,000 $50,000 $60,000
$70,000 $100,000 Other:


Specific Contract:

12/12 12/15 15/12 24/12 PAID


Aggregate Contract:
12/12 12/15 15/12 24/12 PAID

   
   

Please select the following options:

Medical
Short Term Disability
Rx Card
Dental
Vision
Life Insurance
   
The following iInformation is attached to this form or is to be forwarded seperately:

Attached   Separate

Currently Fully Insured

Census
Claims Information (if available)
Large Claim Report (if available)
Complete Benefit Plan Design
Current Rates (previous 2 years)
None

Currently Partially Self-funded

Census
Claims Information
Large Claim Report
Complete Benefit Plan Design
Current Rates
None

   

 






 

IMA

PO BOX 534
Richfield, OH 44286
Phone: 1-866-862-6935