Group Health Insurance
Quote Request Form
DATE
-
Month
-
Day
Year
Date
EMPLOYER NAME
DESCRIPTION OF BUSINESS OPERATIONS
TYPE OF BUSINESS (I.E. LLC, PARTNERSHIP)
FEDERAL TAX ID NUMBER (FEIN)
LOCATION STREET ADDRESS OF BUSINESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MAILING ADDRESS OF BUSINESS (IF DIFFERENT)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOES BUSINESS HAVE MULTIPLE LOCATIONS
YES
NO
MAIN CONTACT
First Name
Last Name
MAIN CONTACT PHONE #
Please enter a valid phone number.
Format: (000) 000-0000.
MAIN CONTACT EMAIL
example@example.com
TOTAL NUMBER OF EMPLOYEES
TOTAL NUMBER OF EMPLOYEES TO BE INSURED
NUMBER OF PART TIME EMPLOYEES
NUMBER OF FULL TIME EMPLOYEES
PERCENTAGE OF PREMIUM TO BE PAID BY EMPLOYER
50%
75%
100%
DOES EMPLOYER HAVE CURRENT COVERAGE
YES
NO
CURRENT INSURER
CURRENT POLICY EXP DATE
-
Month
-
Day
Year
Date
CURRENT PREMIUM AMOUNT
CURRENT GROUP HEALTH INSURANCE POLICY
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