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Ph:425-672-1664

     206-343-5016  

   1-800-987-8150

 

 
 

 

Universal Corporate

Serving Washington and Oregon

 


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SCHOOL INFORMATION 

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COMPANY INFORMATION

           
GENERAL INFORMATION            
Request effective date

No. of full time empl's

Coverage requested for Full time employees        
Full and part time employees
EMPLOYER CONTRIBUTION (MIN 75%)          
Medical

Employee%

 

Dependant%

 
Dental

Employee%

 

Dependant%

 
CURRENT MEDICAL COVERAGE INFORMATION    
Carrier      
Plan          
Deductible

Individual

Family        
Co-Insurance Annual out of pocket limit
Co-Pay (if any)              
Current Dental Coverage        
Carrier        
       
       
       
       
       
Current and renewal rates            
Employee

Medical

Current

Renewal

     
Dental

Current

Renewal

Vision

Current

Renewal

     
Spouse

Medical

Current

Renewal

     
Dental

Current

Renewal

Vision

Current

Renewal

     
Child
Medical

Current

Renewal

     
Dental

Current

Renewal

Vision

Current

Renewal

     
Family

Medical

Current

Renewal

     
Dental

Current

Renewal

Vision

Current

Renewal

     
Life/AD&D Current Rates            
             
           
           
           
           
Short Term Disability Rate            
           
           
           
           
           

 
 
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