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Group Health Insurance

We provide insurance to members of a formal group such as employees of a firm or members of an association. Group insurance is distinguished from individual insurance in which single policies are sold to one person at a time and from social insurance (e.g., unemployment insurance, social security), which is sponsored by the government.

Because every group is different, we take the time to find the right plan for your group. To find out more information, or just check out the rates for group health insurance, fill out our no obligation Group Health Insurance Quote Form below:

 Group Health Quote Request

The quote you have requested requires that you complete the following survey as completely and accurately as possible.  Once submitted the information will be e-mailed to our office(s) and we will expedite your request.  This information will be kept confidential and will be used for quote purposes only.  We look forward to serving you.

 

Contact Information

Company Name:

 Company Address:


Company City:

 State:   Zip:

Type of Business:

SIC Code:

Your Name:

 Your Phone:

Work:

Home: 
   

 Fax: 

 Your Email Address:

 

Type of Coverage

 Doctor Visit Copay:

Yes   No

 Prescription Copay Card:

Yes   No

Plan Type:

Hospital Deductible:

Coinsurance:

Group Life:

Yes   No       Amount:

 Group Dental:

Yes   No

List any specific companies you would like quotes from:

List any major medical conditions associated with this group:
(cancer, diabetes, heart)

 

Employee Census

Please list all employees you wish to cover:

Employee Name

Date of Birth (DOB)

Gender

Spouse DOB
(if applicable)

# of Children

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 have more than 15 employees, simply submit this form additional times.  You will only need to enter the company name on the other submissions.

 

 

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.


Please click on the "Submit Request" button to send us your quote request.

 

 

Copyright 2005 eBenefitsByDesign.com All rights reserved. | 11/20/2006 02:03 PM


 
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