Last update: 01/17/2008

 

 

Sub Menu

  

 

 

 

Group Health Insurance Quote Form
2 to 12 Employees

Please complete the following form and click the "Submit Quote" button to
submit for a free Health Insurance quote.

Company Name:
Address:
City: State: ZIP:
Contact Person:
Area Code and Office Phone: - - Extension:
Area Code and FAX Phone: - -
E-Mail Address:    

General Information

Number of employees to be quoted: Effective date:
Description of business:
Has the company been in business for over one year:   Yes          No
What percent will the company contribute towards benefits: %
Do you currently maintain medical coverage for your employees:   Yes          No
If Insured, select the company insured with:
Select the type of quote and options you would like;
Medical Indemnity HMO / Managed Care PPO
Life Insurance Disability Insurance Dental Care Vision Care

Census Data

Employee
Age:		 Sex:
m/f		 Home
ZIP		 Dependent
Coverage		      Employee
Age:		 Sex:
m/f		 Home
ZIP		 Dependent
Coverage
01:     02:
03:     04:
05:      06:
07:     08:
09:     10:
11:     12:

Questions / Comments

  

 

 

 

Copyright © 1995, 1998, 2000 Santucci Insurance