Medical Group

Information Request Form

Carolina Health Benefits, Inc. is a full service brokerage agency that represents all managed carriers in the Charlotte, NC area. However, on a case-by-case basis we can work with employers out of the Charlotte market. Please complete this form and a local broker will contact you.

Date		Possible Effective Date
Company name		Phone #
Contact name		Fax #
Address City State, Zip County		Type of Business
Contact Email		Website

Total number of full time employees:

Total number to enroll:

Employer will contribute

% of employee

Employer will contribute

% of dependents

Current Carrier

Renewal Month

Current Rates:

E	E/C	E/S	E/F

Please choose desired benefit structure.

Services	Options First Variable is most common	Choice
Managed Care	POS, HMO, PPO
Office Copay	Yes or No
Deductible	Varies among plan
Co-Insurance	90/10, 80/20, 70/30
Stop Loss	$5,000, $10,000
PCS Drug Card	Yes or No
Maternity Coverage	Yes or No
Other Coverage's	Select all that apply

Information about your employees.

	Employee name or initials	Age or DOB	Sex	Spouse DOB	# of dependent children
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If you have additional employees, fax them to (704-588-7971) using this same format.

Serious Medical Conditions

Do you currently work with a broker

Check here if you wish to have an agent contact you prior to quotes being generated.

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