Name
Title/Position
Email Address
Best Time to Call
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:
Do you have existing group health coverage?
Please Select Yes No
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 Select Not Sure January February March April May June July August September October November December
Group Health Insurance
Payroll Deduction Plans
Life & Disability
Dental
Flexible Spending Accounts
Voluntary Benefits
105
h
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:
