Get Your Free Cost Analysis
In order to receive a cost analysis please provide the following information. DISCLAIMER:
Choose from 2 ways to submit your data:
1. Either enter the data in the table below - OR - 2. Upload your own excel file with the following information from Row 1
NOTE: Please include all covered employees and currently enrolled dependents. Dependents should be entered on the line immediately below the employee they are a dependent of. (The more details you’re able to include, the greater the accuracy of the initial quote comparison will be).
Rows
First Name
Last Name
Date of Birth
Gender
Company Name
Home Address
City
State
Zip Code
Relationship to Insured
Enrolled In Plan (Yes or No)
Coverage Type (p
lease select one)
#1
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#2
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#3
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#4
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#5
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#6
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#7
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#8
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#9
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#10
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#11
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#12
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#13
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#14
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#15
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#16
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#17
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#18
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#19
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
#20
Male
Female
Self
Spouse
Dependent
Yes
No
Employee only
Employee + Spouse
Employee + Kids
Family
Waived- no coverage
Want to upload your list instead?
Do you have a group plan size larger than 20 participants, or simply want to upload your own excel file? Copy the required fields from Row 1 (above) and drag and drop your excel sheet (below).
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