Employee Benefits Quote Form

EMPLOYEE
BENEFITS
INSURANCE QUOTE

We would like to provide you with a free, no-obligation group health insurance quote. Please provide as much information as possible to obtain the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Legal Name of Business:
Contact Name:
Address:
City:	State: Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
Contact Email Address:

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:		Optional Pregnancy Coverage:	yes no
Dental Coverage:	yes no	Supplemental Accident Coverage:	yes no
Disability Insurance:	yes no	PCS Card: (Prescription Discount Option)	yes no
Group Life Insurance: Amount:	yes no $	PPO Option:	yes no
Group Life Insurance: Amount:	yes no $	HMO Option:	yes no

Employee Information
Please list all employees you wish to cover:
Employee Name	Date of Birth	Age	Sex	Dependent Status
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
If you were unable 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

Please make any additional comments you feel appropriate for this quote.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.