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PSET Insurance

Disability Protection for Professionals

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MyPSET
Products
Industry Solutions
About PSET
Contact

Complete the Form below to Request a Proposal.

Existing groups please contact PSET directly for changes to current policy. Email Brian@profbci.com for more information.

A. Requestor Information

Name(Required)

First Last

Title(Required)

Email(Required)

Phone

Are You a Broker?(Required)

Yes

No

If yes, Name of Your Agency(Required)

Agency Address(Required)

Street Address Address Line 2 City State ZIP Code

B. Client Information

Legal Name of Group(Required)

Tax Entity (Check One)

S-Corp - Form 1120S

C-Corp - Form 1120

Sole Proprietor - Schedule C

Partnership - Form 1065

Physical Address

Street Address Address Line 2 City State ZIP Code

Does this group have current / prior policy?(Required)

Yes

No

If yes, please upload copy of most current policy.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 32 MB.

Current Rate ($)

Renewal Rate (If Any) ($)

Requested Effective Date

MM slash DD slash YYYY

C. Plan Will Cover: Please Fill in Class Description

Class I(Required)

Class II

Class III

D. Long-term Disability Insurance

Coverage Level (Check One)(Required)

60%

66.67%

Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Monthly Benefit Max (Check One)(Required)

$6K

$8K

$10K

Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Elimination Period (Check One)(Required)

30 Days

90 Days

180 Days

Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Benefit Riders

Cost of Living Adjustment (COLA)

Qualified Medical Condition (QMC) (Physicians Only)

Own Specialty

Assisted Living Benefit (ALB) @ 80%

Assisted Living Benefit (ALB) @ 100%

Lifetime Security Benefit (LSB)

24 Mo Return to Work (Increase From 12 Mo)

24 Mos Survivor Benefit (Increase From 3 Mo)

Childcare Benefit

E. Short-term Disability Income Insurance

Include STD in Quote?

Yes

No

Weekly Benefit Max

$1,000

$1,500

Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Max Benefit Duration (Check One)(Required)

13 Weeks

26 Weeks

Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

Elimination Period

7 Days For Sickness And 0 Days For Accident

14 Days For Sickness And 14 Days For Accident

Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

F. Life Insurance and Accidental Death and Dismemberment

Include Life and AD&D in Quote?

Yes

No

Life & ADD& Requested Amount

1 x Earnings $50,000

1 x Earnings $400,000

2 x Earnings $400,000

3 x Earnings $400,000

Custom

NOTE: Customization available only to Medical & Legal groups, size 15+. All other professions, 35+.

G. Employer Contribution

Employer Contribution(Required)

Contributory (Employee will pay some portion of the premium)

Non-Contributory (Employer will pay 100% of premiums with no cost to employee)

If Non-Contributory

Premium Included : Premiums will be reported on W2 and benefits will be non-taxable

Premium Excluded : Premiums will not be reported on W2 and benefits will be taxed

H. Additional Notes/Requests

Additional Notes/Requests

I. Signature & Census Form

Broker Signature(Required)

By checking this box, I certify that the information on this RFP is complete and accurate.

Signature Date(Required)

MM slash DD slash YYYY

Upload Completed Census Document(Required)

Accepted file types: pdf, xlsx, xls, Max. file size: 32 MB.

(NOTE: Census Document Can Be Downloaded at the Top of This Page)

ABOUT PSET

Since 1982, The Professional Services Employers Trust has provided high quality, cost effective group disability coverage designed specifically for professional services. Our efficient claims processing, exceptional customer service, and stable rates help our clients protect their employees and attract top talent.

HELPFUL LINKS

MyPSET
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Billing Change Form
Contact Us

PROUD PARTNERS

PSET proudly partners with Standard Insurance.

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