Benefit Design Group

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QUOTE ORDER FORM
*These fields are required.

*Company Name:	*Date:
Type of Business:
*Address:
*City:
* State:	*Zip:
*County:
Phone:	Fax:

*Agent:

Contact Person:

*# Full Time Employees:

Current Carrier:

Effective Date:

*Quote the following carriers:

CareFirst
PPN
MPOS
CFS
DHP
Dental
Vision

PHN
HMO Only
Triple Option

United Concordia
Silver
Gold
Gold Choice

Additional
Comments:

Census

Coverage Codes:
1 - Individual
2 - Husband & Wife
3 - Parent/Child
4 - Family

*e.g. 02/14/1970

	DOB*	Age	Sex	Cov.
*1.
2.
3.
4.
5.
6.
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17.

	DOB*	Age	Sex	Cov
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
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33.
34.

	DOB*	Age	Sex	Cov
35.
36.
37.
38.
39.
40.
41.
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47.
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50.

Demographics

<15:	35-39:	60-64:
15-19:	40-44:	65-69:
20-24:	45-49:	70-74:
25-29:	50-54:	75>:
30-34:	55-59:	Medicare A&B:

Individual:
Parent/Child:
Husband/Wife:
Family:

Submission of this form will allow Benefit Design Group, LLC to process the information contained in this document. The Employer agrees to maintain a signed copy of this document. Benefit Design Group, LLC, reserves the right to request a copy of the signed document at any time from the Employer.