Large Group Statement:

•	Employer contributions
•	Eligible employee demographics(date of birth, gender, dependent status or number of dependents, residence zip code)
•	Claims experience for the past three years, if available
•	Detailed information on high claims over $10,000
•	Carrier history (current and past carriers, benefits and premium rates)
•	COBRA and non active participants

PAI will shop the large group market and encourage the carriers to compete for your business. We encourage competitive bidding and efficient plan design. We offer all options including HSA’s to help slow the increase in medical cost. Contact us at:

Park Avenue Insurance Agency
2723 S. Westmoreland Drive
Orlando, FL 32805
Phone: (407)422-6575 / (888)422-6575
Fax: (407) 422-1251
Email: info@parkavenueinsurance.com

Small Group Statement:

We need some basic information about your company and employees in order to create a customized proposal for you. If your company employs less than 50 people, PAI can research the market for small company employee benefits solutions. PAI will coordinate with available insurance carriers and provide you with a variety of options so that you can make the best benefits decision for your company. Most small group carriers utilize medical underwriting to discount or surcharge the manual rate, so additional information may be requested.

An asterisk(*) denotes a Required Field.

*Company Name:
Contact Name:	Date business was established:
Address:
State:		*Zip Code:
Phone number:		FAX Number:
*E-mail:		Referred By:
Requested effective date of coverage:		Lines of Coverage:	Health Dental Life Disability Retirement Cafeteria Plan

Employee Demographics:
List all employees on your payroll who work at least 25 hours per week.

	Gender	Date of Birth	Dependents to be Covered		Residence Zip Code	Participation Status
	Gender	Date of Birth	Spouse	# Children	Residence Zip Code	Participation Status
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2776 S. Westmoreland Drive, Orlando, FL 32805
(407) 422-6575 | Fax: (407) 422-1251

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