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Alaskan Benefit Insurance Consultants

Spencer Biegel dba  
Alaskan Benefit Insurance Consultants  
907-243-1488 Fax 243-1411  
4225 Trapline Drive  
Anchorage, AK 99516-1536  

abic@customcpu.com  




Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.  The average time to complete a group quotation is 2 1/2 weeks.

 

Company Name: *
Company Address: *
Company Phone: *
 Fax:
 E-mail: *
City *
 State *
 		Zip Code *
 Requested effective date: *
Company Contact and nature of business or SIC CODE / industry: *
Current Carriers Name and #Years:
1) Deductibles
250    300    500   
1000    Health Savings Account    A variety of plan choices   
2) Coinsurance
80%/20% to $5,000 or    $10,000   
BOTH   
3) Coinsurance
50%/50% to $5,000 or    $10,000   
Both   
4) DOCTORS OFFICE CO-PAY PLANS
YES    NO   
5) Prescription Drug Card
Yes    No   
6) Prescription Drug Card CO-Pay options
$15/$25/$40    $10/$20/$40    $5/$10   
$5/$15/$30    $10/$20    $10/$15   
$5/$15    A VARIETY   
7) Life Accident Death and Dismemberment
$10K    $15K    $20K    $25K    $50K   
8) Dental
Yes    No   
Deductible
$25    $50   
Annual Max
$1K    $1.5K    2K   
Ortho
Yes    No   
9) Vision
Yes    No   
10) Disability:
Yes    No   
Long or Short Term
Long    Short   
Monthly Max
$1K    $2K    $3K    $5K   
Elimination Period Days
30    60    90    180   
11) Special Needs Supplemental Coverage
Travel Accident    Cancer    Accident    Intensive Care   
12) Retirement Programs: 401K
Yes    No   
13) Section 125 Cafateria plan Pre-Tax Dollar For Flexible Benefit Options
Yes    No   
14) Employee Census Form *
Please List Below All Full-Time elligible Employees and dependents:  
15) Any major health conditions? Employees or Dependents? Please indicate Employee number and condition *

* Required to submit this form












Alaskan Benefit Insurance Consultants

(907) 243-1488 FAX 243-1411 EMAIL abic@customcpu.com

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