Group Benefits
Owner / Company Information
Owner's Name
Contact Number
Email
Company Name
Plan Information *
Category
Basic Plan
Advanced Plan
Drug Maximum
$15,000/yr
$15,000/yr
EMS
Included
Included
Vision
Included
Semi Private
Included
Dental Maximum
$800/yr
$1,000/yr
Travel
Included
Included
Optional hospital coverage:
Yes
Select Plan
Basic Plan
Advianced Plan
Input Owner / Employee Information
Owner / Employee Name
Age
Family Status
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Select Status
Family
Couple
Single with Child
Single
Terms & Conditions
I agree to be contacted by a licensed South Coast FInancial Services Financial Advisor to provide a quote for benefits as outlined above.
I understand that the quotes given are approximate values and the actual value will be presented when I meet with the Financial Advisor.
I agree that I will not hold the Financial Advisor or any affilliates responsible for the quote obtained through this submission.
I agree to the above terms and conditions
Yes
* quotes are based on Green Shield Group Benefit Plans