Group Health Insurance Quote

We would like to provide you with a free, no-obligation group health insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. General Information Legal Name of Business: Contact Name: Address: City:   State:   Zip: Business Phone:   Fax: Best Time To Call:   AM   PM Contact Email Address: Type of Business Type of Business: Standard Industry Code (if known): "# of Full Time Employees:  (working 25 hours or more per week)          # 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     PPO Option: yes  no Dental Coverage: yes  no POS Option: yes  no Disability Insurance: yes  no HMO Option: yes  no Group Life Insurance:   Amount: yes  no $ HSA Compatible Plans: yes  no     Employee Information Please list all employees you wish to cover: Employee Name Date of Birth Age Sex Dependent Status Home ZipCode M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F Emp. OnlyEmp. & SpouseEmp. & ChildEmp. & Family M F 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. Please click on the "Submit Quote" button to send your quote request. One of our representatives will respond to your submission as soon as possible. This Group Health Quote Form Copyright © 1998 - by ENHANCED Web Services

Group Health Insuarnce Group Health Insurance helps you provide medical care for yourself and your employees, ensuring the wellness and productivity of your business. A business health insurance plan helps spread the financial risk between all the members, which usually means lower premiums and more extensive coverage for everyone.