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Group Health Insurance QuoteWe promise to do our best to provide our clients with convenient service.



Contact Information

CONTACT PERSON*
PHONE NUMBER*
FAX NUMBER
E-MAIL ADDRESS*





Mandatory Information

COMPANY ZIP*      % of costs to be paid by Employer
% of Employee costs  % of Dependent costs
NATURE OF BUSINESS
TYPE OF EMPLOYEES TO BE QUOTED
All Non-Union
NO. OF FULL-TIME EMPLOYEE(30+hours/week)
DESIRED EFFECTIVE DATE(mm/dd/yyyy)





Optional Information

COMPANY STRUCTURE
Sole Proprietor Corperation LLC
Partnership Other  
MORE THAN ONE LOCATION?
Yes No If yes, where?  
ANY EMPLOYEES PAID BY COMMISION (and/or) PAID AS INDEPENDENT CONTRACTORS? (from 1009)
Yes No
MOST CURRENT DE-9C AVAILABLE?
Yes No
HOW MANY WEEKS PAYROLL?
ANY COBRA PARTICIPANTS PREVIOUSLY EMPLOYED BY YOU? (if yes, indicate Aip Code on Census located on reverse side)
Yes No
EMPLOYEES LIVING OUT-OF-STATE?
Yes No





Products

All
Medical Plan Designs
All
HMO
HSA
PPO
EPO
Specific Plans 
Dental
Dental PPO
Dental HMO
INO
Prior Coverage  
Life/AD&D
Vision
LTC
LTD
STD





Current Converage Information

CURRENT HEALTH PLAN
CURRENT PREMIUM
CURRENT PLAN TYPE
ARE YOU WITH A PEO?
If yes, # of Years
Yes No
  % Participation
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