group health quote

Group Health Insurance Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Name

Address

Phone

Email Address

What is your position?

Best time to call?

Does your company currently have an insurance carrier?

Please provide the required field.

If so, name of current carrier

Anniversary Date of current plan

Total Number of Employees

Number of Employees to be Insured

Are premiums paid by your company for employee only or spouse too?

Please provide the required field.

Current coverage is for:

Please provide the required field.

Current rate for coverage is:

Please list the companies you would like quoted:

What type of plan do you want compared?

Please provide the required field.

Please choose from the following co-payments:

Please provide the required field.

Would you like a Prescription Plan?

Please provide the required field.

Please choose a deductible:

Please provide the required field.

Please select from the following co-insurances:

Please provide the required field.

What do you like or dislike about your current plan?

Additional remarks or requests

Company Name

Address

Number Of Employees

Zip Code

Employee 1 Name

Birth Date

Gender

Please provide the required field.

Tobacco Use

Please provide the required field.

Spouse Name

Spouse Birth Date

Gender

Please provide the required field.

Tobacco Use

Please provide the required field.

Child 1 Birth Date

Gender

Please provide the required field.

Tobacco Use

Please provide the required field.

Child 2 Birth Date

Gender

Please provide the required field.

Tobacco Use

Please provide the required field.

Employee 2 Name

Birth Date

Gender

Please provide the required field.

Tobacco Use

Please provide the required field.

Child 1 Birth Date

Gender

Please provide the required field.

Tobacco Use

Please provide the required field.

Child 2 Birth Date

Gender

Please provide the required field.

Tobacco Use

Please provide the required field.