Please fill all required fields
RANCHPLAN Benefits Solutions
Quote Request
*=required
*Company Name
*Contact Name
*Phone Number
*Email Address
*Last Name
*First Name
*Coverage (S/C/F/W)
Annual Salary
S
C
F
W
S
C
F
W
S
C
F
W
S
C
F
W
S
C
F
W
S
C
F
W
S
C
F
W
S
C
F
W
S
C
F
W
*Coverage
S = single
C = Couple
F = Family
W = Waived
Once this form has been sent, a representative from Unigroup Inc will be in touch with you.
If you have any questions, please call 1-800-292-9066.
Last Name
First Name
Life Volume
Accidental Death & Dismemberment Volume
Critical Illness Volume
Last Name
First Name
Basic Life
AD&D
Dep. Life
CI
EHC
Dental
Total
Monthly Premium
Benefit
Volume
Rates
Premium
Basic Life
$0.190
Accidental Death & Dismemberment
$0.044
Dependant Life
$2.14
Critical Illness
$0.696
Extended Health Care
Single
$50.60
Couple
$118.50
Family
$141.08
Dental Care
Single
$52.31
Couple
$94.95
Family
$153.17
Monthly Total with Disability
Total Single
Couple
Total Family
Total Waived
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