We would like to provide you
with a free, no-obligation group health insurance quote. Please
provide as much information possible for the most accurate quote. This
information will be kept confidential and will be used for quote purposes
only.
General Information
Legal
Name of Business:
Contact
Name:
Address:
City:
State:
Zip:
Business
Phone:
Fax:
Best Time
To Call:
AM PM
Contact Email
Address:
Type of Business
Type
of Business:
Standard
Industry Code (if known):
#
of Full Time Employees:
# of Part Time Employees:
Give
a complete description of any
type of hazardous/dangerous duties
performed by your employees:
Current Group Health Insurance Information
Carrier
(Company) Name (not agency):
Please give a brief description of your current Group
Health plan:
Benefits Desired
Major
Medical Deductible:
Optional
Pregnancy Coverage:
yes no
Dental
Coverage:
yes no
Supplemental
Accident Coverage:
yes no
Disability
Insurance:
yes no
PCS
Card:
(Prescription Discount Option)
yes no
Group
Life Insurance:
Amount:
yes no
$
PPO
Option:
yes no
HMO
Option:
yes no
Employee Information
Please list all employees you wish to cover:
Employee Name
Date of Birth
Age
Sex
Dependent Status
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
If you were not able to list all employees you wish to cover
in the spaces above,
please use the Additional Comments section below
or indicate that you will fax or email an additional
listing.
Additional Comments
Please give any additional comments you feel appropriate
for this quotation. If you have additional information where there was
not enough space, please enter them here.
Please click on the "Submit Quote" button to send
your quote request.
One of our representatives will respond to your submission as
soon as possible.
