..:: GCADA - Group Insurance Quote Form ::..

Upcoming Events: Seminar Schedule

Body Shop Safety
Wednesday, November 12, 2025 - 1:00pm-3:00pm
9150 S. Hills Blvd. Broadview Heights, OH 44147
SAFE:$0 GCADA Member:$50/pp Non-Member:$100/pp

SAFE Supervisor Meeting
Tuesday, November 11, 2025 - 9:00am-12:00pm
9150 S. Hills Blvd. Broadview Heights, OH 44147
FREE for SAFE Program Members

Service Department Legal Issues - Mayfield
Thursday, November 06, 2025 - 10am-1pm
Holiday Inn 760 Beta Dr. Mayfield Village 44143
Members: $80/pp Non-Member: $160/pp

Forklift Safety Training & Certification - MAPLE HEIGHTS
Tuesday, November 04, 2025 - 9:00am-12:00pm
Liberty Ford Maple Heights
SAFE: $0 GCADA Member: $50/pp Non-Member:$100/p

Forklift Safety Training & Certification - BRUNSWICK
Wednesday, October 29, 2025 - 9:00am-12:00pm
Liberty Ford Brunswick
SAFE: $0 GCADA Member: $50/pp Non-Member:$100/p

Group Insurance Quote Form

Please complete the following information and click the "submit" button.
Contact Information:
Dealer Name
Person Requesting
Address
City, ST, ZIP
Phone
Fax
E-mail Address

Indicate number of employees only, covered in each category:
Single
Employee & Spouse
Employee & Children
Family
COBRA
Total employees currently covered

COBRA eligible, not yet covered
Emplyees eligible, not currently covered
Total emplyees eligible for coverage
Current Policy Information:
Current Group Health Carrier
Date policy expires
	Employee	Emp & Sp	Emp & Child/ren	Family
Current Rates:
Renewal rates if available:
Prior Policy Information:
Prior Group Health Carrier
Date coverage expired
	Employee	Emp & Sp	Emp & Child/ren	Family
Prior Rates:

Are you aware of any serious medical conditions, such as cancer, heart, circulatory
conditions, etc.? If so, please describe below:

Current coverage information:
	In-network	Out of network
Deductibles
Co-insurance
Out of pocket maximums
Prescription co-pays:
Generic
Name Brand
Non Preferred