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:	$200$250$300$500$1,000			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
				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	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
			Male Female	Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family
If you were not able 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 give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

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