Official Name of Employer *
Industry Type *
SIC code
Company Website
Contact Person *
Prefix
First *
Last *
Suffix
Phone Number

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Fax Number

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Location of the Group
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Number of Employees *
Is this a Multi-Location Group?
 YES 
 NO 
If YES, please include the number of employees in each location below with corresponding zip codes.
Employees by Location
Desired Effective Date

MM
/
DD
/
YYYY
Is this group currently self-funded?
 YES 
 NO 
Can we show you a Group Life Insurance quote?
 YES 
 NO 
Current Networks
What PPO Network is being used, if any?
If multiple networks, please indicate by location.
Commission Level Requested
If applicable.

Email Address *
By supplying an email address, you will receive a confirmation email from LifeWell Health Plans with a printable record of your request.

This information will not be sold or used by LifeWell for any other means.
Newsletters?
 YES 
 NO 
Would you like to receive our email newsletter with the latest LifeWell information and tips?

Requested Information from LifeWell

All below requested information can be securely submitted to us in a variety of formats. Typically, PDF, Excel Spreadsheet, or Word Documents will be preferred.
Submit Census
Please submit a current, electronic (i.e. in Excel) census listed by individual. Include the following at a minimum - year of birth or age, sex and type of coverage, medical/dental/vision plan options, COBRA or Retirees notated, and zip codes.
Submit Schedule of Benefits
Please submit a current schedule of benefits and requested benefits, if different.
Submit Monthly Claims
Please submit a target of 3 years worth of monthly claims. This should be listed month by month and include the number of covered employees for each month for the most recent period.
Submit High Claimants
Please submit any high claims or any serious ongoing conditions with diagnosis and prognosis, by year to match up with the claim year.
Submit Shock Claims
Please submit any shock claims in excess of 50% of the current specific deductible/pooling point.
Current & Renewal Rates
Please submit a copy of the most current and/or renewal rates whether fully insured or self-funded.
Quote Due Date Requested

MM
/
DD
/
YYYY

**NOTE: After you click Submit Request you will be directed to our Thank You page. If you are not redirected please scroll up and make sure you have completed all required fields.
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