Group Benefits Questionnaire
   
Thank you for requesting a group insurance quotation from Gaston Insurance Group. We are a full service provider of group and property/casualty products.

To help us narrow our focus on your desired preferences and quote your group as accurately as possible, please check off the types of coverage from the list below and answer the following questions

 
1. Your Name:
2. Your Email:
  Company:
  Your Address:
  City:
  State:
  Zip:
     
3. What types of coverage do you want to offer your employees?
 
Group Health Insurance
Group Life and AD&D Insurance
Group Dental Insurance
Group Long Term Disability
( n/a to start-up companies for 2 years)
   
4. How long have your company been in business?
 
     
5. What is the nature of company's business?
 
     
6. Will the company pay for the benefits or will the employees pay a portion?
  YES    NO
     
7. If not 100% employer paid, what percentage will employee pay?
 
     
8. Are there currently any terminated employees receiving COBRA benefits?
  YES    NO
     
9. Regarding Insurance carriers:
Are there any carriers in particular that you DO NOT want us to look at?
 
     
10. Are there any carriers in particular that you DO want us to look at?
 
   
  Please select plan design preferences from list below
   
Group Health Insurance
a. Type of Plan:
In-Network Option only (HMO)
In /Out of Network Option ( POS & PPO)
PPO (Preferred Provider Organization) only
   
b.
Co-pay for In-Network plans: $10
  $15
  $20
     
c.
Co-insurance for Out of Network plans: 70%
  80%
     
d.
Deductible Out of Network Plans $250
  $500
  $1,000
     
e.
Prescription drug card: YES NO
     
f.
Maximum out of pocket (out of network) for single: $2,000
  $5,000
  $10,000
     
   
Group Life and AD&D Insurance:
a.
Requested Life and AD&D amount: 1x salary
  2x salary
  Flat Amount:
   
b.
Is there currently any coverage in force? YES NO
If yes, with whom:
If yes, how much:
c.
If you wish us to quote Supplementary Life (employee paid): 1x salary
  2x salary
  Flat Amount:
   
Group Dental Insurance:
a.
Deductible: $50
  $100
     
b.
Want Preventive care subject to deductible? YES NO
     
c.
Annual Maximum: $1,000
  $1,500
     
d.
Type of plan: Indemnity
  PPO (in & out of network options)
   
e.
Is there currently any coverage in force? YES NO
If yes, with whom:
If yes, how much:
Group Long Term Disability:
a.
Waiting period: 90 days
  180 days
     
b.
Monthly maximum:
   
c.
Is there currently any coverage in force? YES NO
If yes, with whom:
If yes, how much:
   

Any other comments?

 
 
 

Through Gaston & Associates, Inc. you can purchase a complete line of insurance coverages that will protect your business. Since Gaston & Associates, Inc. only work with the major carriers and because we can pick and choose among the best policies, you can be assured to receive the best coverage options available in the market.

Gaston & Associates, Inc. keeps you insured as your business grows. We are focused on your needs, whether you are just starting out, or growing faster than you can keep up. We provide you the insurance you need because you can do anything for the success of your business, except travel back in time.

Concerned About Privacy
If you prefer not to submit this information over the Internet, please download the following, and then either fax or email us the completed forms:

1. Either download our MS Word document or Adobe PDF version of the Group Benefit Questionnaire.
   
2. Either download our Excel Spreadsheet or Adobe PDF version of the Group Census Form.
   
3. Fax the completed forms to 914.244.1056 or email to fgaston@gastonassoc.com