Group Quote Form

Group Quote Form

If you would like more information, please call 800-660-1728 or complete the following form.

(* denotes a required field)

ABOUT YOU

First Name:*

Last Name:*

Your Title/Position:*

Your Email Address:*

BUSINESS INFORMATION

Company Name:*

City:*

State:*

Zip Code:*

Country:*

Phone Number:*

Best Time to Contact:*

Nature of Business:*

(e.g. - machine shop, lawyers...)

Number of Employees:*

(full time only - 30+ hours)

CURRENT INSURANCE SITUATION

Does your company currently offer group health insurance?*

If you do not currently offer coverage, you do not need to answer the next 4 questions. You can use the CTRL key to make multiple selections.

Name of Current Insurance Carrier:

Types of insurance currently offered:

Reasons for Dissatisfaction with existing plan:

Month of Renewal of Existing Coverage:

PLAN PREFERENCES

Use the CTRL key to make multiple selections.

Types of coverage you would like quotes on:*

Additional Insurance Options Wanted:

ADDITIONAL COMMENTS

Please provide any additional specific information about your group that will help us recommend a medical plan to meet your needs and/or budget.Include any brief information about preexisting conditions that you are concerned about obtaining coverage for.

By hitting the Submit button, I hereby acknowledge that the information in this form is true and complete to the best of my knowledge.

THANK YOU!

Within the next 1-3 business days we will either ask for additional information or e-mail price and summary information to the address provided. You are welcome to provide additional information about your needs by completing the brief survey below.

CENSUS FORM:

(EE=employee, ES=employee+spouse, EC-empl+chiild(ren), FAM=family)

Gender	Age	Coverage	Gender	Age	Coverage

By hitting the Submit button, I hereby acknowledge that the information in this form is true and complete to the best of my knowledge.