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

Upcoming Events: Seminar Schedule

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

Forklift Safety Training & Certification for Dealership Employees
Wednesday, December 04, 2024 - 9am-12pm
Ken Ganley Honda
SAFE: $0 GCADA Member: $50/pp Non-Member:$100/pp

Professional Automotive Sales - Next Level Training - Building Value and More!
Monday, November 18, 2024 - 8:30am-4:00pm
GCADA - 9150 S. Hills Blvd. Broadview Hts. 44147
Members: $285/pp Non-Members: $500

F&I Manager's Guide to Compliance - YOUNGSTOWN / BOARDMAN
Thursday, October 24, 2024 - 10:00am-1:00pm
Holiday Inn Youngstown / Boardman
Members: $75/pp Non-Member: $150/pp

F&I Manager's Guide to Compliance - MAYFIELD
Thursday, October 17, 2024 - 10:00am-1:00pm
Holiday Inn Cleveland-Mayfield 780 Beta Dr. 44143
Members: $75/pp Non-Member: $150/pp

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