Group Health Insurance

Group Health Insurance Quote

  • 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 paysType of Employee to be Quoted 
  • # of Full Time Employees (30+ Hours Week)% of Costs Paid by Employer for Employee% of Dependant Costs PaidType of Employee tobe Quoted 
  • Current Health PlanCurrent PremiumCurrent Health Plan TypeAre you a PEO?Does Group have Current Dental Coverage?If Yes, Number of Years?% of Participation 
  • Employee ID #Enter E= Employee, S= Spouse, D=DependantLast Name, First NameDate of Birth (MM/DD/YYYY)GenderResidence Zip CodeIs Employee on COBRA?