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:

Select 50/50 70/30 80/20 90/10 100/0

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

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

Male
Female

NA 1 2 3 4 5 6 7 8 9 10

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.