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

Upcoming Events: Seminar Schedule

2024 Workers' Compensation & Safety Management Seminar - Boardman
Thursday, May 16, 2024 - 11am-1:30pm
Holiday Inn Boardman
Complimentary - GCADA WC Program Participants

2024 Workers' Compensation & Safety Management Seminar- Cuyahoga Falls
Thursday, May 09, 2024 - 9am-11:30am
Sheraton Suites Cuyahoga Falls
Complimentary: GCADA WC Program Participants

HAZMAT Training, Testing & Certification
Tuesday, April 30, 2024 - 9am-12pm
9150 S. Hills Blvd. Broadview Heights, OH 44147
SAFE: $0 GCADA Member: $45/pp Non-Member:$90/p

2024 Workers' Compensation & Safety Management Seminar - Independence
Friday, April 19, 2024 - 9am-11:30am
Independence Civic Center
Complimentary: GCADA WC Program Participants

2024 Workers' Compensation & Safety Management Seminar- North Ridgeville
Wednesday, April 17, 2024 - 11am-1:30pm
Ridgefield Recreation Center
Complimentary: GCADA WC Program Participants

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