Shore Benefits Brokerage - Health & Life Insurance
Shore Benefits Brokerage
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Shore Benefits Brokerage
 
 
"questions on group or health insurance?" Call 1-800-777-1459
   
  Contact Shore Benefits Brokerage
  If you would like to simply send an email to Shore Benefits Brokerage without filling out the following form please email us at shorebb@aol.com
 
Client  Information
First Name:     
Last Name:    
Phone Number:    
Fax Number:    
E-mail Address:
City:    
State:    
Zip:    
Nature of Business:    

How do you want to receive your quote by?
  Fax
  E-Mail  

Census Information

Date Of Birth
(mm/dd/yyyy)

Age Sex Dependant Status Life Amount Salary
M F $ $
M F $ $
M F $ $
M F $ $
M F $ $
M F $ $
M F $ $
M F $ $
M F $ $
M F $ $

Medical Plan Designs
Type of Plan Design

  HMO
  POS
  PPO 
Rx Card

  $5/$10
  $15
  Least Expensive  
Co-Pay

  $10
  $15
  $20  
Waive Hospital Co-pay
Waive Hospital Co-pay
Deductible

  $250
  $500
  $1000  
Co-Insurance

  70%
  80%

Dental Plan Designs

Please check all that apply

Deductible

  $25
  $50
  $100  
Waive for Preventative
Waive for Preventative
Maximum Annual

  $1000
  $1500 
Orthodontics
Orthodontics

Long Term Disability

Would you like a LTD quote? Yes No
Would you like a Group Life Quote? Yes  No

Questions / Comments

Please type any questions or comments that you have.

       

   
 
Shore Benefits Brokerage. PO Box 1. Allenhurst. NJ 07711
Toll Free: 800-777-1459   /   Local: 732-531-8339   /   Fax: 732-517-1079
 
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