Group Health Quote Form

For more than 10 emplovees please contact our office

Company Name:
Address:
City:		State:		Zip:
Contact Person:

Area Code and Office Phone:	- -	Extension:
Area Code and FAX Phone:	- -

General Information


Number of employees to be quoted:

Effective date:

Description of business:

Has the company been in business for over one year:

Yes No

Will the company contribute towards benefits, if so indicate percent:	%
Do you currently maintain medical coverage for your employees:	Yes No

Select the type of quote and options you would like;

Medical Indemnity		PPO		HMO/Managed Care
Dental		Vision Care		Life Insurance		Disability

Census Data


Employee Age:	Sex: m/f	Home ZIP	Dependent Coverage		Employee Age:	Sex: m/f	Home ZIP	Dependent Coverage
01:			No Coverage Spouse Only Children Only Family		02:			No Coverage Spouse Only Children Only Family
03:			No Coverage Spouse Only Children Only Family		04:			No Coverage Spouse Only Children Only Family
05:			No Coverage Spouse Only Children Only Family		06:			No Coverage Spouse Only Children Only Family
07:			No Coverage Spouse Only Children Only Family		08:			No Coverage Spouse Only Children Only Family
09:			No Coverage Spouse Only Children Only Family		10:			No Coverage Spouse Only Children Only Family

Questions / Comments / Or any additinal information

your request or the form.