McAlpin Agency, Inc.

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Employee Benefits

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If you live outside of Minnesota click on the Agency Link System

Agency Link System

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We feature a full line of Health Care Insurance Plans including Major Medical Plans, HMO Plans, Dental Insurance & Short & Long Term Disability Income from Companies such as Blue Cross & Blue Shield of MN, Blue Plus, Delta Dental, Fortis, Health Partners, MEDICA &  MII Life.

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Small Group Health Care Rate Quote Request Form

This is a request for a Minnesota insurance quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Insurance rates are subject to change.

General Information

Name
Company Name
Street
City, State ZIP

County Located
E-mail
Phone
Fax
Agent Request

General Information on Your Employees

Total Number Number working more than 20 hours/week Number working more than 20 hours/week waiving coverage
Number participating Number employed in Minnesota More than 49 employees in the previous calendar year?
Yes No

General Information on Employer

Percentage Employer contributes toward Employee Cost Current Health Care Carrier Renewal Date

Companies Plans Requesting Information On

Blue Cross Blue Shield of MN
Blue Plus MN
Health Partners
John Alden Life
MEDICA

Additional Benefits

Life Insurance Yes No
Short Term Disability Insurance Yes No
Long Term Disability Insurance Yes No
Dental Insurance Yes No
If yes, do you have Dental Insurance now Yes No

Employee Census

(The Employee Name is optional, Sex and Employee Date of Birth (DOB) are mandatory, Spouse's DOB must be included if requesting coverage, Children's ages must be included if requesting coverage and should be separated by commas, Monthly Salary is needed if requesting Disability Benefits).
 

Employee Name

 Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
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Employee Name

 Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
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  Employee Name Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
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  Employee Name Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
31.
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  Employee Name Sex M/F Employee DOB Spouse DOB Dependent Children Ages Monthly Salary
41.
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46.
47.
48.
49.

Please comment on any employees over 65 and not on Medicare.

Additional Comments

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Send mail to mwsmith@visi.com with questions or comments about this web site.

Michael W. Smith Agency

Copyright © 1997 Michael W. Smith Agency
Last modified: July 13, 2000