Shildt Financial Services
210 W. Hamilton Avenue
State College, PA 16801
800-211-7819 (Toll-Free)
234-1419 (Local Area)

shildtfs@aol.com



 



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CHART A COURSE FOR YOUR EMPLOYEE BENEFITS INSURANCE



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HEALTH/MEDICAL, DENTAL, AND VISION PROPOSAL REQUESTS

PLEASE PROVIDE:

(1) Gender for each employee and dependent for Health/Medical coverage. Gender for employee only for Dental and/or Vision coverage.  

(2) Date Of Birth for each employee and dependent for Health/Medical coverage. Date Of Birth for employee only for Dental and/or vision Vision. 

(3) Zip Code for each employee and dependent for Health/Medical coverage. Zip Code for employee only for Dental and/or Vision coverage.

(4) Employee Coverage Status--Single, Employee/Spouse, Employee/Child, Employee/Children, or Family.

(5) Tobacco Usage--for Health/Medical coverage only--for each employee and dependent indicate if there has been any tobacco usage within the last six months. 

(6) Present Carrier and benefits or desired benefits.

(7) COBRA Information: employees on Cobra with their benefits termination date.

(8) Groups with 50 or more employees--please call us as we may need additional information.

We will meet with you to help you attain this information or you can fax or e-mail it to us. We can also fax you a census form to compile the above information.

If you already have this information on your computer, or wish to compile it on your computer, you may also choose to upload it to us. Please click on our E-Mail Address in the top left corner of the page if you wish to do this.

THANK YOU!!












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To Use Us
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SHILDT FINANCIAL SERVICES

"CHART A COURSE FOR YOUR EMPLOYEE BENEFITS INSURANCE"

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Disability**Pensions & 401(k)**Long Term Care



"THANK YOU FOR CONSIDERING
SHILDT FINANCIAL SERVICES WHERE
WE ALWAYS STRIVE TO EXCEED YOUR EXPECTATIONS"

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