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: *	Select One... $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 Card): *	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 starting with yourself:
Employee Name *	Date of Birth *	Age *	Sex *	Dependent Status *
			Male Female	Select One... Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & Family
			Male Female	Emp. Only Emp. & Spouse Emp. & Child Emp. & 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

IMPORTANT: PLEASE LET US KNOW HOW YOU FOUND US IE: RADIO what station?, YELLOWPAGES, REFERAL, SEARCH INDICATE WHAT SEARCH ENGINE and 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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