Group Health Insurance Quote Request

Please complete the following information and Census Form if you would like to obtain a group health insurance quote. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

If you have more than 50 employees, just submit the form twice. You only need to enter the company name and your email address on the second form, along with the employee information

What is your name? *

First Middle Last

What is the name of your Company?

What is your address?

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

What is your position?

What is your telephone number?

What is the best time to call?

What is your fax number?

What is your e-mail address?

Does your company currently have an insurance carrier?

Yes No

If you have a carrier, who is it?

If you have a carrier, what is the anniversary date of your current plan?

Month Day Year Date Picker Icon

What is the total number of employees in your company?

How many employees are you looking to insure?

Are premiums paid by your company for employee only or family, too?

Employee Only Employee and Family

My current monthly rate for coverage is:
(enter amount into corresponding box)

Single

Husband and Wife

Single Parent and Child

Full Family

Other

Are there insurance carriers you would like quoted? If yes, please list the company names.

What type of plan do you want compared?

Co-Payments

If you want an HMO or Dual Option Plan compared, do you want a prescription plan?

Yes No

If you want Dual Option Plan compared, please choose from the following deductibles:

Co-Insurances

What do you like or dislike about your current plan?

Additional remarks or requests.

Enter the message as it's shown *

For a FREE quote, click on the "Submit" button below.