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: $200$250$300$500$1,000     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 Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family Male Female Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family 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.

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