We’ve made getting a quote, simple. Step 1 of 4 - Company 0% Company InformationBusiness Name* Contact* Title* Phone*Email* DetailsPrimary Address* Zip* # Full-time Employees* # Part-time Employees* Federal ID # (If Known) Business DescriptionTell us about your company's products, services and employees' job functions. BenefitsAre you interested in providing benefits to your employees through Emplicity? Yes No Click 'Next' to continue. Benefit TypeSelect Desired Benefits Below: Medical Dental Vision Life LTD STD 401k Supplemental Not Sure Please complete the fields below:MedicalRenewal MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberInsurance Company or Provider Network Employer Contribution ($ or %)Employee Dependent Attach most recent master payroll register: Drop files here or Select files Max. file size: 32 MB. DentalRenewal MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberInsurance Company or Provider Network Employer Contribution ($ or %)Employee Dependent VisionRenewal MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberInsurance Company or Provider Network Employer Contribution ($ or %)Employee Dependent LifeRenewal MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberInsurance Company or Provider Network Employer ContributionEmployee Long-Term DisabilityRenewal MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberInsurance Company or Provider Network Employer ContributionEmployee Short-Term DisabilityInsurance Company or Provider Network Employer ContributionEmployee 401kInsurance Company or Provider Network Employer Contribution SupplementalInsurance Company or Provider Network Employer ContributionEmployee Dependent Number of benefit eligible employees(50% of eligible employees must be enrolled in the benefit plan, excluding union, part-time, temporary/seasonal, COBRA participants, employees in the waiting period and employees enrolled through another group policy.) Number of enrolled employees Number of COBRA participants(COBRA participation may not exceed 10% of enrolled employees.) To your knowledge has any employee, dependent or person to be covered had claims over $10,000 in the past 12 months? Yes No To your knowledge is any employee, dependent or person to be covered unable to work for an extended period of time due to an injury or illness? Yes No To your knowledge are there any current pregnancies or hospitalizations in the past 12 months for any employee, dependent of an employee or person covered? Yes No To your knowledge is any employee, dependent or person to be covered ever had, consulted for, had treatment rendered, been advised to have treatment or received treatment, or been hospitalized for any of the following conditions:- Cardiovascular disease or heart attack? Yes No - Disorder of the kidney? Yes No - Chronic disorder of the stomach, intestine or liver? Yes No - Mental or nervous condition; central nervous disorders? Yes No - Diabetes, respiratory disorders; cancer; brain tumor; blood disorders or transplant? Yes No To your knowledge has any employee, dependent or person to be covered ever been diagnosed as having AIDS or aids-related complex (ARC) by a medical professional? Yes No For each Yes answer, please provide the following information (Provide additional information in an attached document if necessary.)Condition (Diagnosis) Age Date Diagnosed Prognosis Date of Services Total Chargers (Est.) Attach additional documents here, if needed: Drop files here or Select files Max. file size: 32 MB. By continuing, I declare that the above answers and statements are true and correct to the best of my knowledge. Workers' CompensationAre you interested in Workers' Comp? Yes No Do you have more than 5 Workers' Comp Classifications? Yes No Click 'Next' to continue.Please upload a file with each workers' compensation class code listed individually -- if you do not currently have workers' compensation insurance, please complete the number of employees under each job description as well as their combined yearly remuneration. If you currently have a workers' compensation policy, please also list your current rates for each class code. Please include: State Code (If known) Class Code Description Effective Rate Per $100 of Payroll (If known) # Full-time Employees (Over 30 hrs/week) # Part-time (Under 30 hrs/week) Estimated Annual PayrollFile Drop files here or Select files Max. file size: 32 MB. Please list each workers' compensation class code individually below--if you do not currently have workers' compensation insurance, please complete the number of employees under each job description as well as their combined yearly remuneration. If you currently have a workers' compensation policy, please also list your current rates for each class code. Workers' Comp Classification #1StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCODE (If Known) Effective Rate Workers' Comp Class Code Description (If Known) #Full-timeOver 30 hrs/week #Part-timeUnder 30 hrs/week Estimated Annual Payroll Workers' Comp Classification #2StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCODE (If Known) Effective Rate Workers' Comp Class Code Description (If Known) #Full-timeOver 30 hrs/week #Part-timeUnder 30 hrs/week Estimated Annual Payroll Workers' Comp Classification #3StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCODE (If Known) Effective Rate Workers' Comp Class Code Description (If Known) #Full-timeOver 30 hrs/week #Part-timeUnder 30 hrs/week Estimated Annual Payroll Workers' Comp Classification #4StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCODE (If Known) Effective Rate Workers' Comp Class Code Description (If Known) #Full-timeOver 30 hrs/week #Part-timeUnder 30 hrs/week Estimated Annual Payroll Workers' Comp Classification #5StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCODE (If Known) Effective Rate Workers' Comp Class Code Description (If Known) #Full-timeOver 30 hrs/week #Part-timeUnder 30 hrs/week Estimated Annual Payroll CommentsThis field is for validation purposes and should be left unchanged.
