GROUP HEALTH INSURANCE QUOTE REQUEST

Please complete the following information and Census Form if you would like to obtain a group health insurance quote. Please understand this is not an application for insurance. 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.
If you have more than 50 employees, just submit the form twice. You only need to enter the company name and your email address on the second form, along with the employee information.
Personal Information
What is your name?
Last
First
Middle
What is the name of your company?
Company's Name
What is your address?
Street
City
State
Zip
What is your position?
Position
What is your e-mail address?
e-mail
What is your telephone number?
Telephone
What is your fax number?
Fax
What is the best time to call?
Time to Call
Does your company currently have an insurance carrier?
Carrier
 Yes No
If you have a carrier, what is it?
Name of Current
Carrier
If you have a carrier, what is the anniversary date of your current plan?
Anniversary
Date
What is the total number of employees in your company?
Total Number of
Employees
How many employees are you looking to insure?
Number of
Employees
to be Insured
Are premiums paid by your company for employee only or family, too?
Employee Only
Employee and Family
My current rate for coverage is:
Single
Husband & Wife
Single Parent &
Child
Full Family


Are there insurance carriers you would like quoted?
If yes, please list the company names
What type of plan do you want compared?
HMO Plan
Dual Option Plan
(PPO/POS)
 HMO Plan
Dual Option Plan
If you want an HMO or Dual Option Plan compared, choose from the following co-payments:
Co-payments
If you want an HMO or Dual Option Plan compared, do you want a prescription plan?
Prescription Plan
 Yes No
If you want Dual Option Plan compared, please choose from the following deductible:
Deductible
If you want Dual Option Plan compared, please choose from the following co-insurances:
Co-insurances
What do you like or dislike about your current plan?
Likes or Dislikes
Additional remarks or requests
Remarks or
Requests
For a quote click on the submit button below
Census
Company Name
State
City
Zip
Employee Data
Employee No.
Birth Date (mm/dd/yy)
Gender
Select Coverage
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