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Group Health Insurance Quote Request Form

General Information
Legal Name of Business  
Contact Name  
Address  
City, State, Zip     
Business Phone  
Best time to call     AM   PM
Email Address  

 

Type of Business
Type of Business
Standard Industry Code (if known):
# of Full Time Employees:
# of Full Time Employees:    
Give a complete description of any type of hazardous and/or dangerous duties performed by your employees:  

   

 

 

Current 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 Prescription Discount Card Yes  No
Group Life Insurance Yes  No PPO Option Yes  No
Group Life Insurance Amount HMO Option Yes  No

 

Employee Information

Please list all employees you wish to cover
 Employee Name Date of Birth  Age Gender 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  

This information will be kept confidential and will be used for quote purposes only.