Group Ancillary Plans Step 1 of 2 50% Adviser Information Adviser InformationAre you new to working with Secura Consultants?*YesNoAre you new to working with Secura Consultants?Adviser Name*Adviser NameCompany Name*Company NamePhone*PhoneCommission Amount*Flat PercentageStandardCommission AmountFlat Percentage Amount*10%15%20%25%Flat Percentage AmountFax*FaxAddress* Street Address City State / Province / Region ZIP / Postal Code AddressEmail* Email Company Information Company InformationCompany Name*Company NameIndustry/SIC Code*Industry/SIC CodeAddress* Street Address City State / Province / Region ZIP / Postal Code AddressYears in Business*Years in BusinessWebsiteWebsiteRequested Effective Date:*Requested Effective Date: Lines of Coverage Please check the box next to the lines you are requesting and fill in the details for each line of coverage. Lines of Coverage Life & AD&D Class I Flat Amount*$ for all Full-Time EmployeesClass I Flat AmountClass II Flat Amount*$ for all Full-Time EmployeesClass II Flat AmountMultiple of Earnings*x Earnings on all Employees to Max Benefit of $Multiple of EarningsDependent Life Amount*Dependent Life AmountDependent Life Amount*Dependent Life AmountVoluntary?*YesNoVoluntary?Attach Life Claims Experience*Attach Life Claims ExperienceCurrent RatesCurrent RatesRenewal RatesRenewal Rates Dental Deductible Amount*Deductible AmountAnnual Maximum*Annual MaximumOrthodontics?*YesNoOrthodontics?Lifetime Maximum*Lifetime MaximumPreventive*PreventiveBasic*BasicBasic*BasicVoluntary?*YesNoVoluntary?Current RatesCurrent RatesRenewal RatesRenewal RatesSHORT TERM DISABILITY SHORT TERM DISABILITY SHORT TERM DISABILITYClass I Flat Amount*$/week on all Full-Time Employees Class I Flat AmountClass II Flat Amount*week on all Full-Time Employees Class II Flat AmountPercent of Earnings*% of Earnings to a Max Benefit ofPercent of Earnings*$ / weekUntitled*13 Weeks26 WeeksSSNRAUntitledElimination Period (Benefits Begin)*day(s) accidentElimination Period (Benefits Begin)*day(s) illnessAttach STD Claims Experience*(Groups of 100+)Attach STD Claims ExperienceVoluntary?*YesNoVoluntary?Current RatesCurrent RatesRenewal RatesRenewal RatesLONG TERM DISABILITY LONG TERM DISABILITY LONG TERM DISABILITYElimination Period* 90 Days 120 Days 180 Days Elimination PeriodBenefit Duration* 2 Years 5 Years To Age 65 SSNRA Benefit DurationOwn Occ Definition* 2 Years 3 Years 5 Years To Age 65 SSNRA Own Occ DefinitionOwn Occ Definition*(Groups of 200+)Own Occ DefinitionVoluntary?YesNoVoluntary?Current RatesCurrent RatesRenewal RatesRenewal RatesWORKSITE PRODUCTS WORKSITE PRODUCTS WORKSITE PRODUCTSWorksite Benefits: Simply select the worksite products you’re interested in and one of our sales consultants will be in contact with you for more information.* Accident Hospital Confinement Indemnity Critical Illness Disability (Short Term Only) Cancer Insurance Term Life Worksite Benefits: Simply select the worksite products you’re interested in and one of our sales consultants will be in contact with you for more information.VISION VISION VISIONMaterials Only?*YesNoMaterials Only?Coverage Amount Specified (Lenses, frames, contacts, etc.)?*dollarsCoverage Amount Specified (Lenses, frames, contacts, etc.)?Exams (how often)?*Exams (how often)?Voluntary?YesNoVoluntary?Notes or Special Requests if not specified aboveNotes or Special Requests if not specified above Attachments AttachmentsFileFileFileFileFileFileFileFileFileFileCaptchaCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.