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 Group Health 2 to 24

  

Last update: 03/21/2008

 

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Group Health Insurance Quote Form
2 to 24 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, name the company insured with:
Select the type of quote and options you would like;
Medical Idemnity HMO / Managed Care PPO HSA
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:
13:   14:
15:   16:
17:   18:
19:   20:
21:   22:
23:   24:

 

Questions / Comments

  


 

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