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Upcoming Events: Seminar Schedule
Service Department Legal Issues - Boardman
Thursday, June 20, 2024 - 10am-1pm
Holiday Inn Boardman
Members: $75/pp Non-Member: $150/pp
Service Department Legal Issues - Mayfield
Thursday, June 13, 2024 - 10am-1pm
Holiday Inn Mayfield
Members: $75/pp Non-Member: $150/pp
Service Department Legal Issues - Cuyahoga Falls
Thursday, June 06, 2024 - 10am-1pm
Sheraton Suites Cuyahoga Falls
Members: $75/pp Non-Member: $150/pp
Service Department Legal Issues - North Olmsted
Thursday, May 23, 2024 - 10am-1pm
Courtyard Cleveland Aiport North
Members: $75/pp Non-Member: $150/pp
2024 Workers' Compensation & Safety Management Seminar - Boardman
Thursday, May 16, 2024 - 11am-1:30pm
Holiday Inn Boardman
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