Agent -- Group Health Quote Form

GROUP
HEALTH
INSURANCE QUOTE We would like to provide you with a free, no-obligation group health insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quoting purposes only.

General Information
Legal Name of Business:
Contact Name:
Address:
City:	State: Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
Contact Email Address:

Type of Business

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:

Current Group Health 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 PCS Card:
(Prescription Discount Option) yes  no

Group Life Insurance:

Amount:
yes  no
$
PPO Option: yes  no

HMO Option: yes  no

Employee Information

Please list all employees you wish to cover:

Employee Name Date of Birth Age Sex 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

Male
Female

Male
Female

Male
Female

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.

Additional Comments

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.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


GROUP HEALTH INSURANCE QUOTE		We would like to provide you with a free, no-obligation group health insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quoting purposes only.

Type of Business
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:

Current Group Health 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	PCS Card: (Prescription Discount Option)	yes no
Group Life Insurance: Amount:	yes no $	PPO Option:	yes no
Group Life Insurance: Amount:	yes no $	HMO Option:	yes no

Employee Information
Please list all employees you wish to cover:
Employee Name	Date of Birth	Age	Sex	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
			Male Female
			Male Female
			Male Female
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.