Contact Information

• Company Name:
• Company Address:
• Company City / State / Zip: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Type of Business:
• SIC Code:
• Your Name:
• Your Home Zipcode:
• Home Phone Number:
• Work Phone Number:
• Fax Number:
• Your Email Address:

Type of Coverage

• Doctor Visit Copay: Female Male
• Prescription Copay Card: No Yes
• Plan Type: Select HMO PPO POS Traditional Indemnity Hospital & Surgical Only
• Hospital Deductible: Select $250 $500 $1000 $1500
• Coinsurance: Select 50/50 70/30 80/20 90/10 100/0
• Group Life: Female Male
• Amount:
• Group Dental: Female Male
• List any specific companies you would like quotes from:
• List any major medical conditions associated with this group: (cancer, diabetes, heart)

Spouse/Companion Information

Please list all employees you wish to cover:
Employee Name	Date of Birth (DOB)	Gender	Spouse DOB (if applicable)	#of Children
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
		Male Female		NA 1 2 3 4 5 6 7 8 9 10
If you have more than 15 employees, simply submit this form additional times. You will only need to enter the company name on the other submissions.

Additional Considerations / Requests

• Please give any additional comments you feel appropriate for this quotation.