Dunn & Associates Insurance, Inc.
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Home :  About :  Staff :  Personal Coverages :  Business Coverages :   Financial Coverages :  Employee Benefits : 
Individual Life & Health : Contact


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Employee Benefits Form


General Information
Date: 
Employer:  Phone:  Fax #: 
Address: 
City:   County:    State:    Zip: 
Contact Person:  Email: 
Type of  Business: 
Current Carrier:    Plan:    Eff. Date: 
Need copy of current bill and outline of coverage.


Coverages to be  quoted:  Health   Dental    Short Term Disability   Other
% Paid by  Employer:     %      %               %               %


Census Information
Need current UCT-6 - Quarterly Tax Report
 Current Coverage Codes:
 0=Not Covered, Waived, Life Insurance Only or in Benefit Waiting Period (not currently enrolled);
 1=Employee Only; 2=Employee & Child(ren); 3=Employee & Spouse; 4=Employee & Family
Employee  Gender  Date of
 Birth		  Current
 Coverage
 (0, 1, 2, 3, 4)		  Eligible
 Employee's
 Home Zip  Code		  Date of  Hire
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Additional Comments
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Home :  About :  Staff :  Personal Coverages :  Business Coverages :   Financial Coverages :  Employee Benefits : 
Individual Life & Health : Contact


Dunn & Associates Insurance, Inc.

Phone: (386) 255-2477

324 W. International Speedway Blvd.

Fax: (386) 255-3573

Daytona Beach, FL 32114-4289

Email: info@dunn-insurance.com

© Dunn & Associates Insurance, Inc.