Group benefits insurance information request

Complete and submit this form to have a representative connect with you about Humana Group Benefits insurance.

Required fields

1. Tell us about yourself

Name

Phone number

Email

2. Tell us about your company

Company name

Phone number

Headquarters address

Total number of employees

Total number of W-2 employees

3. Tell us about your insurance needs

What type of coverage are you interested in?

Dental

Vision

Life

Short-term disability

Long-term disability

Coverage Start Date: mm/dd/yyyy

Do you currently offer group coverage?

Dental

Vision

Life

Short-term disability

Long-term disability

No

If so, who is your current carrier?

Are you currently working with a broker?

Yes

No

Broker/Agency name:

Our agent will need a census for quoting. Can you provide a census when the agent reaches out to you? A census includes the names, dates of birth, genders and home ZIP codes of the employees (and their dependents) who need coverage.

Yes

No

“Humana” is the brand name for plans, products and services provided by one or more of the subsidiaries and affiliate companies of Humana Inc. (“Humana Entities”). Plans, products, and services are solely and only provided by one or more Humana Entities specified on the plan, product, or service contract, not Humana Inc. Not all plans, products, and services are available in each state.

Humana legal entities that offer, underwrite, administer or insure insurance products and services.

Individual Dental and Vision Plans

Humana Individual dental and vision plans are insured or offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of New York, The Dental Concern, Inc., CompBenefits Insurance Company, CompBenefits Company, CompBenefits Dental, Inc., Humana Employers Health Plan of Georgia, Inc. or Humana Health Benefit Plan of Louisiana, Inc. Discount plans offered by HumanaDental Insurance Company or Humana Insurance Company. For Arizona residents: Insured by Humana Insurance Company. For New Mexico residents: Insured by Humana Insurance Company. For Texas residents: Insured or offered by Humana Insurance Company, HumanaDental Insurance Company or DentiCare, Inc (d/b/a Compbenefits).

Group Dental and Vision Plans (Insurance through your employer)

Humana group dental plans are insured, offered, or administered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of New York, The Dental Concern, Inc., Humana Medical Plan of Utah, Inc., Humana Health Benefit Plan of Louisiana, Inc., CompBenefits Company, Humana Employers Health Plan of Georgia, Inc. or DentiCare, Inc. (d/b/a CompBenefits). In Arizona, group dental plans are insured by Humana Insurance Company. In New Mexico, group dental plans are insured by Humana Insurance Company. In Texas, group dental plans are insured by Humana Insurance Company or Humana Dental Insurance Company or offered by DentiCare, Inc. (d/b/a CompBenefits).

Humana group vision plans are insured or offered by Humana Insurance Company, Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company of New York, or The Dental Concern, Inc. In Arizona, group vision plans are insured by Humana Insurance Company. In New Mexico, group vision plans are insured by Humana Insurance Company. In Texas, group vision plans are insured by Humana Insurance Company.

Group Life Insurance Plans (Insurance through your employer)

Humana group life plans are insured by Humana Insurance Company or Humana Insurance Company of Kentucky. In Arizona, group life plans are insured by Humana Insurance Company. In New Mexico, group life plans are insured by Humana Insurance Company. In Texas, group life plans are insured by Humana Insurance Company.

Group Disability Income Insurance Plans (Insurance through your employer)

Humana group disability income plans are insured by Humana Insurance Company or Humana Insurance Company of Kentucky. In Arizona, group disability income plans are insured by Humana Insurance Company. In New Mexico, group disability income plans are insured by Humana Insurance Company. In Texas, group disability income plans are insured by Humana Insurance Company.

Limitations and exclusions

This communication provides a general description of certain identified insurance or non-insurance benefits provided under one or more of our health benefit plans. Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. For costs and complete details of the coverage, refer to the plan document or call or write your Humana insurance agent or the company. In the event of any disagreement between this communication and the plan document, the plan document will control.

Statements in languages other than English contained in the advertisement do not necessarily reflect the exact contents of the policy written in English, because of possible linguistic differences. In the event of a dispute, the policy as written in English is considered the controlling authority.

Individual applications are subject to eligibility requirements.

Before applying for group coverage, please refer to the pre-enrollment disclosures for a description of plan provisions which may exclude, limit, reduce, modify or terminate your coverage. View plan provisions or check with your sales representative.

For group plans, please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description/Administrative Services Only) for more information on the company providing your benefits.

© Humana 2025

Last updated: XX/XX/XXXX