Life & Disability Insurance Please fill out the form below.

SBAM OneAmerica Quote Request

Agent Name(Required)

Agency Name(Required)

Agent Email Address(Required)

Agent Phone Number(Required)

Company Name(Required)

Company Contact Name(Required)

Requested Effective Date(Required)

Minimum Hours Per Week To Be Eligible(Required)

Definition of eligible full-time employment can be as high as 40 hours per week or as low as 20 hours per week for employees and owners.

Basic Employee Life/AD&D(Required)

Employee Life: $10,000–$500,000, not over 5× annual salary. Only available in increments of $10,000. Guarantee issue: $100,000. Include on the Census Employee Election Amounts.

Basic Dependent Life/AD&D(Required)

Yes

Spouse Coverage = $5,000. Child coverage: $2,000 (6 months to age 26) and $500 (birth to 6 months). Dependent Life/AD&D can only be purchased in conjunction with Basic Life/AD&D

Basic Employee STD(Required)

Basic Employee LTD(Required)

Voluntary Coverage

Employee Voluntary Life/AD&D(Required)

Yes

Employee Life: $10,000–$500,000, not over 5× annual salary. Only available in increments of $10,000. Guarantee issue: $100,000. Include on the Census Employee Election Amounts.

Spouse Voluntary Life/AD&D

Yes

$5,000–$25,000, not over 50% of employee Life. Include on the Census Employee Election Amounts.

Child Voluntary Life/AD&D

Yes

Child Life: $1,000 birth–6 months; $10,000 after 6 months. Include on the Census Employee Election Amounts.

Voluntary Employee STD

Voluntary Employee LTD

Upload Census(Required)

Max. file size: 50 MB.

Please upload your census for employees enrolling including Names, DOB, Annual Salary. if electing Voluntary coverage, include Benefit Amounts for each.

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