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UNITEL – Ancillary Benefits Request Form

1 Company Contact Information

2 Coverage Options

3 Census and Policy Upload

Group Information
Company Name*
Primary Contact Name*
First Last
Primary Contact Email Address*
Primary Contact Phone Number*
I'm interested in the following benefits lines*
- Select All
- Life/AD&D
- Short-term Disability
- Long-term Disability
- Dental
- Vision
- Executive Benefits
Choose all that apply

Life/AD&D
Current Benefit Amount*
- 1 x Salary
- 2 x Salary
Retiree coverage*
Board of Directors Coverage*
Voluntary life offered*
Dependent life amount*
Please enter a number greater than or equal to 0.
Short-term Disability
Benefit Duration*
- 13 Weeks
- 26 Weeks
% of Income Replacement*
- 50%
- 60%
- 66.66%
- 70%
Weekly maximum benefit (STD)*
Waiting period for illness*
Waiting period for injury*
Long-term Disability
Elimination Period*
- 90 days
- 180 days
% of Income Replacement*
- 50%
- 60%
- 66.66%
- 70%
Monthly maximum benefit*
Medical Premium Waiver Offered?
Retirement plan waivers offered?
Any special contract provisions?

Census*
Complete and upload an employee census using this
Census Template
Drop files here or
Policies
Upload copies of current policies
Drop files here or
Current Bill
Upload a copy of a current bill.
Drop files here or

Locations

1128 Lincoln Mall, Suite 200
Lincoln, NE 68508
____

12120 Port Grace Blvd, Suite 102
La Vista, NE 68128
____

2457 33rd Avenue
Columbus, NE 68601
____

1317 W Pasewalk Ave #200
Norfolk, NE 68701

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© 2016 UNICO Group, Inc.

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Midlands Financial
UNITEL
Legal Statements

Eligible Risks

Acceptable MVR’s

• No more than 3 moving violations in 3 years
• No more than 1 accident and 3 moving violations in 3 years
• No more than 2 accidents and 1 moving violation in 3 years
• No major violations

Unacceptable MVRs

Drivers with any of these violations in the past three years

• Hit and Run Conviction
• Fleeing or Eluding Police
• Manslaughter or Negligent Homicide
• DUI or DWI
• Any Felony Conviction
• Racing
• Driving Under a Suspended License
• Reckless Driving

Eligible Trucks

• OTR Tractor (Class 7 or higher)

Ineligible Vehicles

• Tow trucks or wreckers
• Private passenger vehicles or mobile homes
• Commercial mini, cargo or cube vans
• Antique vehicles
• Emergency vehicles
• Vehicles garaged in AK, HI or MA (Call 402-625-7246 to discuss coverage options)