Kilpatrick

Quote Requests

To request a quote from our office, download the appropriate form below and complete. If you choose to use your own forms, please review ours to verify that your information is complete. Doing so will help reduce quote turnaround times and potential for errors. A group’s market segment is determined by the average total number of employees employed in the calendar year prior to the effective/anniversary date. This number is critical for quoting purposes.

Group Benefits

File Comments Updated
Census Template for Small Groups Census template relevant for small group medical quoting. See Group Form and ACA Census in separate sheets. 2015-09
Census Template for Large Groups Census template relevant for large groups and self-funded groups. Omit columns that do not apply. 2015-09
Claim Requests Each carrier has their own process.
Benefits RFP For fully insured large groups. Small group RFP form is contained within Small Group census template above. 2016-08
Self-Funded Medical RFP and checklist for groups that have a current self-funded medical plan. Includes claims requests for medical, dental, and vision. 2016-08
Large Group Data Requirements Checklist of claim data requirements for each line of coverage. Includes checklist of other document requirements. 2016-08
Payroll and HR Form Allows us to quote payroll and HR services. 2011-12

Occupational Accident and Workers Comp

File Comments Updated
Non-Subscription One page form required to quote occupational accident options. 2010-02
Workers Compensation Application and request form for workers comp quotes. 2013-09