Individual / Family Benefits
Plan Information *
Category
Basic Plan
Advanced Plan
Drug Maximum
$15,000/yr
$15,000/yr
EMS
Included
Included
Vision
Included
Semi Private
Included
Dental Maximum
$800/yr
$1,000/yr
Travel
Included
Included
Optional hospital coverage:
Yes
Select Plan
Basic Plan
Advianced Plan
Personal / Family Information
Name
Age
Family Status
Phone Number
Email
Select Status
Family
Couple
Single with Child
Single
Terms & Conditions
I agree to be contacted by a licensed South Coast FInancial Services Financial Advisor to provide a quote for benefits as outlined above.
I understand that the quotes given are approximate values and the actual value will be presented when I meet with the Financial Advisor.
I agree that I will not hold the Financial Advisor or any affilliates responsible for the quote obtained through this submission.
I agree to the above terms and conditions
Yes
* quotes are based on Green Shield Benefit Plans