Please provide us some general information about your
group. A Vicary Insurance Agency representative will contact you to discuss
your group insurance situation.
Contact Information
Business
Information
Business Name:
Street Address:
City:
State:
Zip Code:
Nature of your business:
Phone:
Fax:
# of full-time employees:
# of employees enrolled in group plan:
Years In Business:
Your Current Group Health Insurance Situation
Do you have existing group health coverage?
Name of current group health insurance company
Current Rate Information
Employee Only
Employee + Spouse
Employee + Children
Employee + Family
Month of Renewal for Current Coverage:
Please
indicate the group insurance products that you are interested in:
Group Health Insurance
Payroll Deduction Plans
Life & Disability
Dental
Flexible Spending Accounts
Voluntary Benefits
105
Additional Comments
Please include short comments regarding any
meaningful on-going medical conditions among the employees and
dependents to be covered by a new health plan:
Are there any other issues you want us to
consider? If so, please summarize:
