Group Health Quote Request
You must fill in the form as complete and accurately as possible for the quote requested.The information will be e-mailed to our offices and reviewed in order to expedite your request. Your information is confidential and will be used only by our company for the purpose of this quote
Fields marked with a
Red
asterisk
*
are required. Fields marked with a
Blue
asterisk
*
, at least 1 of the fields must be filled in.
*
Company Name:
Company Address:
Company City:
State:
Zip:
Type of Business:
SIC Code
*
Your Name:
*
Your Home Zipcode
*
Your Work Phone
*
Your Home Phone
Fax:
*
Your e-mail address
COVERAGE TYPE
Dr Visit Copay
Yes
No
Prescription Copay Card
Yes
No
Plan Type
HMO
PPO
POS
TRADITIONAL INDEMNITY
HOSPITAL AND SURGICAL ONLY
Hospital Deductable
$250
$500
$1000
$1500
Coinsurance
50/50
70/30
80/20
90/10
100/0
Group Life
Yes
No
Group Dental
Yes
No
Amount
List any Specific companies you would like quotes from:
List any major medical conditions associated with this group: (cancer, diabetes, heart)
EMPLOYEE CENSUS
Please list all employees you wish to cover.
Employee Name
Date of Birth
Spouse Dob (if applies)
# of children
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
Please give any additional comments you feel appropriate for this quotation
Please click on the
"Submit Request"
button to send us your quote request.
