Group Health Plans

Company Name:*
Contact Name:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email:
Tel#:
Fax#:
Proposed Effective Date:
Date Format: MM slash DD slash YYYY
Current Carrier:
Current Renewal Date:
Date Format: MM slash DD slash YYYY
Company Structure:
- Sole Proprietor
- Corporation LLC
- Partnership
Type of Business:
More than one location?
Number of Full Time Employee's (30+ hours/ week)
Please enter a number from 1 to 100.
How many weeks payroll?
Please enter a number from 1 to 100.
# of Cobra's:
Please enter a number from 1 to 100.
% of Employee Costs
% of Dependent Costs
Types of Employees to be quoted:
Employees Living Out of State:
Industry SIC Code:
Are you interested in other products?
- Life
- Dental
- LTD
Known Medical Conditions: (please describe)
Employees:
Employee Name Gender Date of Birth isMarried? # of Children ZIP COBRA
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Comments
This field is for validation purposes and should be left unchanged.

Employee Name	Gender	Date of Birth	isMarried?	# of Children	ZIP	COBRA