Group health insurance quote request form

Please provide us as much information as possible for the most accurate quotes and we would be glad to provide you with free and no obligation group health insurance quotes from multiple companies.

The information you provide will be kept strictly confidential and will be used for quote purposes only.

Please note that not all plans are available in all states.


Contact Information
Business Name *
Type of Business *
Please try to be descriptive.
SIC Code
Not sure? Search
Address
City
State *
Zip Code *
Day Phone
Evening Phone
Fax
Best time to reach you
Email *


Present Plan
Present Carrier
Renewal Date
mm/dd/yyyy
Worker Compensation Carrier
Premiums
 Excellent  Good  OK  Concerned
Benefits
 Excellent  Good  OK  Concerned
List of Providers
 Excellent  Good  OK  Concerned
Claims Service
 Excellent  Good  OK  Concerned
Agent/Broker Service
 Excellent  Good  OK  Concerned
Other:
 Excellent  Good  OK  Concerned
Other:
 Excellent  Good  OK  Concerned


New Plan Preferences
   Medical   Prescription Drugs   Maternity   Well Baby Care
  Dental   Vision   Short Term Disability   Long Term Disability
  Group Life Insurance   Additional Life Insurance   Health Savings Account (HSA)
Preferred plan types: (Check all that apply)   PPO   HMO   POS   Indemnity   Self-Insured



Answer the following questions for employees and their dependents. How many proposed applicants have/are:
Number of Instances

Currently pregnant? If any, give due date:
Any other comments:
Total Number of Employees*
Number of Employees Need Coverage *



Fields with * are required fields.