Group Insurance Quote Group Insurance Quote Form Company Name Federal Tax ID Group Admin Contact Email Phone Number Fax Number Street Address City State Province Postal Zip Code Nature of Business Number of Employees Part-Time EE's EE's on Cobra Years in Business Years in Business Propose Effective Date Do you currently have medical insurance? Yes No Name of Carrier WHICH benefits are most important to you and your employees? HMO PPO HSA OTHER Primary Physician Co-Pay $15 $25 $35 $50 Other Prescription Drug Card $4/$35/$50 $15/$45/$60 $25/$60/$85 Other * Wellness Yes No Ortho included in Dental Yes No Dental Annual Max $1000 $1250 $1500 Other Life Insurance $15000 1 Times Salary Other Flexible Spending Account Yes No Health Reimbursement Account Yes No Option 3 401-K Plan Yes No Undergone any treatment for physical illness during the past 12 months that resulted in expenses in excess of $5,000? Yes No Undergone Surgery? Yes No Been treated for or advised of a heart condition, cancer, stroke, AIDS, renal disease or diabetes? Yes No Pregnant? Yes No Contemplating hospitalization, or been advised to seek treatment or been scheduled for hospitalization and/or surgery? Yes No At or near maximum benefit dollars under any portion of the current program? Yes No Other Information: Please complete for all questions answered "YES". Thanks! If you have your most recent invoice, please upload here: INVOICE If you have your benefit highlights for all lines of coverage, please upload here: BENEFIT HIGHLIGHTS Send
