Group Health Insurance Quote Form
All information will be kept in house and confidential!

* Required Information

*Company Name:
*Nature Of The Business:      SIC Code (if known)  
Contact Name:
*Email Address:
Address:
*City:   *State:   *Zip:  
Phone #:   Fax #:  

Present Health Insurance Carrier:  
Deductible:   Co Insurance:   Stop Loss:  
Dental:  Yes No Maternity:  Yes No Life:  Yes No ,   If Yes, Amount  

*Requested Coverage:  PPO    HMO    POS    Any Doctor
*Deductible:  $0 $250 $500 $1000 $1500 $2000 *Co Insurance:  100% 90% 80% 60%

*Stop Loss:  $2500 $5000 $7500 $10000

*Dental:  Yes No *Maternity:  Yes No *Life:  Yes No ,   If Yes, Amount  

*Name of Employee *DOB/AGE *Sex (M/F) *Med Coverage Code *# Children
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For groups larger than 14 employees, please resubmit form with Business Name and additional employee information.