Group Health Insurance Quote General Information Type of Business Current Health Insurance Information Benefits Desired Employee Information Additional Comments Legal Business Name Contact Name Address City State Zip Code Business Phone Best Time To Call AM PM Email Address Proceed Type of Business Standard Industry Code (if known) # of Full Time Employees # of Part Time Employees Give a complete description of any type of hazardous/dangerous duties performed by your employees Back Proceed Current Health Insurance Carrier (Not Agency) Please give a brief description of your current Group Health plan: Back Proceed Major Medical Deductable $200$250$300$500$1000 Dental Coverage Yes No Disability Insurance Yes No Group Life Yes No Group Life Amount Optional Pregnancy Coverage Yes No Supplemental Accident Coverage Yes No PCS Card (Prescription Discount Option) Yes No PPO Option Yes No HMO Option Yes No Back Proceed Employee Name Date of Birth Age Sex Male Female Dependent Status Employee OnlyEmployee and SpouseEmployee and ChildEmployee and Family Employee Name Date of Birth Age Sex Male Female Dependent Status Employee OnlyEmployee and SpouseEmployee and ChildEmployee and Family Employee Name Date of Birth Age Sex Male Female Dependent Status Employee OnlyEmployee and SpouseEmployee and ChildEmployee and Family Employee Name Date of Birth Age Sex Male Female Dependent Status Employee OnlyEmployee and SpouseEmployee and ChildEmployee and Family Employee Name Date of Birth Age Sex Male Female Dependent Status Employee OnlyEmployee and SpouseEmployee and ChildEmployee and Family Are there more employees? Back Proceed Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here. This includes If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or email an additional listing. Back Send
