New Business Transmittal Form (Must be fully completed & submitted with all Business)
Date: _ ___________________________ Group Number: _ _________________________ Group Name: _____________________________________
Name of Insured Product #1 Premium Product #2 Premium Product #3 Premium Product #4 Premium Product #5 Premium Product #6 Premium
Total Premium Total # of Apps Total # of EE’s
Total Monthly $ Total Annual $
To ensure an accurate initial bill is generated, new business should be received by the Home Office before the requested date of coverage.
NBT 0225
The ManhattanLife Family of Companies
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