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:

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Benefits Desired
Major Medical Deductible:	-Select-$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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