Group Ancillary Plans Step 1 of 2 50% Adviser Information Are you new to working with Secura Consultants?*YesNoAdviser Name*Company Name*Phone*Commission Amount*Flat PercentageStandardFlat Percentage Amount*10%15%20%25%Fax*Address* Street Address City State / Province / Region ZIP / Postal Code Email* Company Information Company Name*Industry/SIC Code*Address* Street Address City State / Province / Region ZIP / Postal Code Years in Business*WebsiteRequested 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. Life & AD&D Class I Flat Amount*$ for all Full-Time EmployeesClass II Flat Amount*$ for all Full-Time EmployeesMultiple of Earnings*x Earnings on all Employees to Max Benefit of $Dependent Life Amount*Dependent Life Amount*Voluntary?*YesNoAttach Life Claims Experience*Current RatesRenewal Rates Dental Deductible Amount*Annual Maximum*Orthodontics?*YesNoLifetime Maximum*Preventive*Basic*Basic*Voluntary?*YesNoCurrent RatesRenewal RatesSHORT TERM DISABILITY SHORT TERM DISABILITY Class I Flat Amount*$/week on all Full-Time Employees Class II Flat Amount*week on all Full-Time Employees Percent of Earnings*% of Earnings to a Max Benefit of*$ / weekUntitled*13 Weeks26 WeeksSSNRAElimination Period (Benefits Begin)*day(s) accident*day(s) illnessAttach STD Claims Experience*(Groups of 100+)Voluntary?*YesNoCurrent RatesRenewal RatesLONG TERM DISABILITY LONG TERM DISABILITY Elimination Period* 90 Days 120 Days 180 Days Benefit Duration* 2 Years 5 Years To Age 65 SSNRA Own Occ Definition* 2 Years 3 Years 5 Years To Age 65 SSNRA Own Occ Definition*(Groups of 200+)Voluntary?YesNoCurrent RatesRenewal RatesWORKSITE PRODUCTS WORKSITE PRODUCTS 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.* Accident Hospital Confinement Indemnity Critical Illness Disability (Short Term Only) Cancer Insurance Term Life VISION VISION Materials Only?*YesNoCoverage Amount Specified (Lenses, frames, contacts, etc.)?*dollarsExams (how often)?*Voluntary?YesNoNotes or Special Requests if not specified above Attachments FileFileFileFileFileCaptcha This iframe contains the logic required to handle Ajax powered Gravity Forms.