GENERAL INFORMATION

Contact Name

Contact Email

Name of Business

Nature of Business

Business Address

Business City, State, Zip

Business Phone

Business Fax

LIFE & AD&D COVERAGE

Number of Employees

Number of Employees Eligible

Current Carrier

Renewal Date

Current Rate

Renewal Rate

Flat Amount

GROUP HEALTH COVERAGE

Number of Employees

Number of Employees Eligible

Current Plan

HMO
POS
PPO
Indemnity

Plan to Quote

HMO
POS
PPO
Indemnity

Desired Deductible

Desired Co-Pay

Desired Co-Insurance

GROUP DENTAL COVERAGE

Number of Employees

Number of Employees Eligible

Class A Deductible

Class B Deductible

Class C Deductible

Class A Co-Insurance

Class B Co-Insurance

Class C Co-Insurance

Calendar Year Maximum

GROUP DISABILITY COVERAGE

Number of Employees

Number of Employees Eligible

Current Plan

Current Carrier

Renewal Date

Current Rates STD

Renewal Rates STD

Elimination Period STD

Percentage Payable STD

Maximum Benefit STD

Duration Benefit STD

Current Rates LTD

Renewal Rates LTD

Elimination Period LTD

Percentage Payable LTD

Maximum Benefit LTD

Duration Benefit LTD

COMMENTS

Comments

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Disclaimer

I agree to the following:

I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of Top O' Michigan Insurance *

Group Medical and Non-Medical Benefits

Because your employees deserve the best!

Use this form to request a quote. Fill out only the fields in the areas that you are requesting a quote for coverage on. Although the coverage fields are not required, please fill out the areas you want to the best of your ability so we can provide you with an accurate quote. To assist in a complete employee benefits solution, please use the group census template below for information gathering.

Our Locations

Alpena
514 N Ripley Blvd
Alpena, MI 49707

(989) 356-6133

Hillman
150 State St
Hillman, MI 49746

Local: (989) 742-4574

Oscoda
117 S State St
Oscoda, MI 48750

Local: (989) 739-1461

Traverse City
3183 Logan Valley Rd
Traverse City, MI 49684

Local: (231) 947-1164

Mio
607 S Morenci Ave
Mio, MI 48647

Local: (989) 826-3989

Iron River
117 W Genesee St, Ste 1
Iron River, MI 49935

Local: (906) 265-5137

Petoskey
322 Bay St, Ste 1
Petoskey, MI 49770-4401

Local: (231) 347-4610

Gaylord
440 W Main St, Ste F
Gaylord, MI 49735-1401

Local: (989) 705-8664