Jessica – Financial Designs

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Services
About Us
- Employee Benefits Brokers
- Concierge Team
Contact Us
Get Started
Client Tools

About Jessica

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Financial Designs Inc.
786-388-0030
8000 NW 7th St. Suite 201
Miami, FL 33126

Providing benefits packages for your company. We make it simple.

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PHONE *

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WHAT SERVICES ARE YOU INTERESED IN FOR YOUR COMPANY?

Health Insurance (Medical, Dental, Vision)

Disability Policies

Life Insurance

Group Retirement

Business Consulting Services

HR Services

Payroll Services

Workers' Compensation

Financial Designs Wealth - Financial Services

All of the above

ADDITIONAL INFORMATION

Employee Enrollment Form

FD Nationl - Enrollment Form

Company Name

Employee Name

Employee Contact Number

Email Address

Gross Income

Ocupation

Employee DOB

Social Security NO.

Gender

Male

Female

Address

City

State

Zip Code

All Lines of Coverage

All Lines of Coverage

Medical

Medical

Gap

Gap

Vision

Vision

Dental

Dental

STD

STD

LTD

LTD

Life

Life

AD&D

AD&D

Primary Care Physician Full Name: (phone number) Facilities cannot be assigned

> Dependent Coverage

Spouse

Child

Dependent Name

Dependent DOB

Social Security No.

Gender

Male

Female

All Lines of Coverage

All Lines of Coverage

Medical

Medical

Gap

Gap

Vision

Vision

Dental

Dental

STD

STD

LTD

LTD

Life

Life

AD&D

AD&D

Primary Care Physician Full Name: (phone number) Facilities cannot be assigned

> Dependent Coverage

Child

Dependent Name

Dependent DOB

Social Security NO.

Gender

Male

Female

All Lines of Coverage

All Lines of Coverage

Medical

Medical

Gap

Gap

Vision

Vision

Dental

Dental

STD

STD

LTD

LTD

Life

Life

AD&D

AD&D

Primary Care Physician Full Name: (phone number) Facilities cannot be assigned

> Dependent Coverage

Child

Dependent Name

Dependent DOB

Social Security NO.

Gender

Male

Female

All Lines of Coverage

All Lines of Coverage

Medical

Medical

Gap

Gap

Vision

Vision

Dental

Dental

STD

STD

LTD

LTD

Life

Life

AD&D

AD&D

Primary Care Physician Full Name: (phone number) Facilities cannot be assigned

**Primary care physicians only required if coverage is through Neighborhood Health and BCBS**

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Employee Termination/Coverage Adjustment Form

FD National - Termination Form

Company Name

Employee Name

Email Address

Employee DOB

Effective Date

Dependent Coverage

Spouse

Child

Dependent Name:

Dependent DOB:

All Lines of Coverage

Employee Only

Dependent

Medical

Employee Only

Dependent

Gap

Employee Only

Dependent

Vision

Employee Only

Dependent

Dental

Employee Only

Dependent

STD

Employee Only

Dependent

LTD

Employee Only

Dependent

Life

Employee Only

Dependent

AD&D

Employee Only

Dependent

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