Group Health Insurance Quote

Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. 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.

*Company Name
Number of Employees
Contact Information
*First Name
*Last Name
Contact Company Name and Address (if different from above) Company Name

Street Address


What is your position?
*Email Address
Phone Number
Best time to call?  Morning Afternoon Evening Anytime
Does your company currently have an insurance carrier?  Yes No
  If yes, name of current carrier?
Anniversary Date of current plan
Number of Employees to be Insured
Are premiums paid by your company for employee only or spouse too?  Employee Only Employee and Spouse
Current coverage is for:  Single Husband & Wife Single Parent & Child Full Family
Current rate for coverage is:
Please list the companies you would like quoted:
What type of plan do you want compared?  HMO Plan Dual Options (PPO-POS)
Please choose from the following co-payments:  $5 $10 $15 $20 $30 $40
Would you like a Prescription Plan?  Yes No
Please choose a deductible:  $500 $1000 $1500 $2000 $3000 $4000 $5000
Please select from the following co-insurances:  100/0 80/20 70/30 50/50
What do you like or likes/dislike about your current plan?
Additional remarks or requests
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