HIP THROUGH MHL BUSINESS GROUP
PREMIUM QUOTE SHEET

Name of Company: _____________________________

Effective Date Requested: _____________________________

Plan Selections
(Check One)

HIP PRIME VALUE (20/500/75/50) WITHOUT RX (OPTION 1)

HIP PRIME VALUE (20/500/75/50) WITH RX RIDER (OPTION 2)

HIP PRIME (15/0/35) WITH RX (OPTION 3)

HIP PRIME (10/0/35) WITH RX & OTHER RIDERS (OPTION 4)

STATUS NUMBER OF INSURED X PREMIUM QUOTE  =  TOTAL ($)
Single ________________ ________________ ________________
Employee & Child ________________ ________________ ________________
Employee & Spouse ________________ ________________ ________________
Family ________________ ________________ ________________
Total ________________ ________________ ________________

(As administrator of plan, please make premium check payable to MHL Business Group)

_____________________________ ___________________
Broker Name & Zip Code

 

 Date

 
_____________________________ _________________________ ______________
Broker Signature Phone Number Code #

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