Ralph Moss Limited

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Please select your job description
Owner President C.E.O.
H.R.Manager Benefits Manager Controller Other

Company Name:

Type of business :

Street Address :

P O Box or Suite#:

City: Province:

Postal Code: -

Telephone #: [] - FAX #: [ -

You may need to access our system in the future. In order to avoid the data entry we will ask you to use your full phone number, including area code and a security code. Please give your date of hire which will be your security code:
mm-dd-yy - -

Please tell us about your present benefits plan.

Your Current Group Benefits Insurer is?

What month does your Policy Renew?

Total # of full time employees on your current plan?
Total # of part time employees on your current plan?

Group Life

Do you have Group Life? YES No
If yes, give face amount or % salary:
(ie. Flat $25,000 or 1x, 2x, 3x annual salary)

Do you have Dependent Group Life? Yes No
If yes, give face amount for Spouse:
Each Child:

Can your employees purchase additional optional life coverage? Yes No
If Yes, Enter Face Amount or formula, i.e., 1X, 2X, 3X...salary:

Is your group life insurer the same company as your group health insurer? Yes No
If no, give group life carrier name:

Group Dental Plan

Do you have a group dental plan? Yes No

If no, Scroll Down to the next section.

Group Dental Carrier Name:
Deductible Amount $:
Deductible Type

Dental Co-Pay for:

Basic Level I&II: Major Restorative: Orthodontic:

What is your annual maximum benefit for
Basic Level I & Il ? Major Restorative? Orthodontic ?
Is the maximum for Basic & Major Combined? Yes No

Group Disability

Do you have long term disability? Yes No

If no, Scroll Down to the next section.

L.T.D. Plan Design
Elimination period. (Usually 30, 60, 90 or 180 days)
The monthly benefit is % of Salary.
The maximum monthly amount benefit payable is .
What is the benefit duration? (Usually 2 years, 5 years, to age 65, to age 70 )
Please Select the Own Occupation Period
(This is the length of time that an employee is considered disabled if an employee cannot perform his/her OWN job. Usually 2 years, 5 years, to age 65, to age 70 )

Short Term Disablity

Do you have a Short Term Disability Plan also known as Weekly Indemnity? Yes No

If no, Scroll Down to the next section.

Plan Design
Coverage begins on the day after an accident or the day of sickness.
Benefits are payable for weeks.
The weekly benefit amount is % of the employee's weekly wages.
Does the max. weekly benefit equal the U.I.C. max. Yes No
If no, the maximum is weekly benefit is per week.

Extended Health Care Plan

Do you have an Extended Health Care Plan? Yes No

If no, Scroll Down to the next section.

Plan Design

What is your Annual Deductible:
Single: $25 Family: $25

If deductibles are OTHER what are they:?

Single: Family: per year.

What are the Co-Insurance Amounts:
Drugs: Hospital Practioners

Does your plan include Out-Of-Country Travel Medical coverage? Yes No
If yes, what is the Lifetime Maximum Benefit per person

Does your plan include Prescription Drugs? YES NO
If Yes are the following included?
Birth Control pills : YES NO
Fertility Drugs?: YES NO
Smoking Cessation Aids?: YES NO
Pay Direct Drug Card?: YES NO

Does your plan include Vision Care? YES NO
If Yes, What is the benefit: $ every Months.

If there anything regarding the benefits of your plan not covered by the questions above or to leave any comments that may aid us in supplying a proposal please use the text area below.?

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