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EMPLOYEE DISABILITY CENSUS
 
Company: * Contact: *
Address: * City: *
State: * Zip Code: *
Phone: * Fax: *
Type of Business: * SIC Code: *
Number of FTP Employees: *
Email: *
 
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Please answer the following questions so that we can make an accurate comparison:
 
1. Who is your current insurance company?
2. What are your current premiums?
3. How much will the employer contribute to the premiums?
4. Is this disability benefit voluntary?
5. What elimination period (30,60,90,120)?
6. What effective date would you like?
7. Are you interested in short-term disability or additional life?
To fax in this form, please print this PDF document and fax to us at (317) 803-4222.
 
 
Copyright © Nefouse & Associates, Inc. All Rights Reserved. Benefits are subject to change. Description of insurance plans does not guarantee coverage.