Group Health Insurance Quote

Contact Name
First Last
Company Name
Address
Street Address City State / Province / Region ZIP / Postal Code
More than One Location (Other Location(s)) click the plus sign (+) to add)
Are there More than One Location (Other Location(s)) If Other Location(s) - Where?
Email
Phone
Desired Effective Date:
Company Structure
- Sole Proprietor / Individual
- Corporation
- LLC
- Partnership
- Other
Business Group Info:
Nature of Business # of Full Time Empl (30+/week) % Empl Costs Employer pays % Dependant Costs Employer pays Type of Employee to be Quoted
Business Group Info (Continued)
# of Full Time Employees (30+ Hours Week) % of Costs Paid by Employer for Employee % of Dependant Costs Paid Type of Employee tobe Quoted
Proposal Type Select All that Apply Summary Proposal Custom Proposal Employee Proposal California Choice Choice Builde
- Select All
- All
- Summary Proposal
- Custom Proposal
- Employee Proposal
- California Choice
- Choice Builder
Products You Want Quoted
- Select All
- All
- Medical
- Dental
- Vision
- Life
- Long Term Care
- Short Term Disability
- Long Term Disability

Current Coverage Information

Current Health Plan	Current Premium	Current Health Plan Type	Are you a PEO?	Does Group have Current Dental Coverage?	If Yes, Number of Years?	% of Participation

Employee Census (Must be at least 2 Employees) Click plus (+) sign to add insured person(s)

Employee ID #	Enter E= Employee, S= Spouse, D=Dependant	Last Name, First Name	Date of Birth (MM/DD/YYYY)	Gender	Residence Zip Code	Is Employee on COBRA?

Are there More than One Location (Other Location(s))	If Other Location(s) - Where?

Nature of Business	# of Full Time Empl (30+/week)	% Empl Costs Employer pays	% Dependant Costs Employer pays	Type of Employee to be Quoted

# of Full Time Employees (30+ Hours Week)	% of Costs Paid by Employer for Employee	% of Dependant Costs Paid	Type of Employee tobe Quoted