Kansas Preferred Insurance Group - Group Health Quote Sheet
913-585-1981 34102 Commerce Dr Ste B De Soto, KS 66018 www.kpigroup.net
Company Name:
*
Nature of Business:
*
Contact Person Name:
*
Requested Effective Date:
*
Total Number of Full Time Employees:
*
Number of Employees To Be Covered:
*
Address:
*
Street Address
Street Address Line 2
City
Please Select
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State
Zip Code
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
SMS Communication Consent:
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Employee Name:
Employee Gender:
Please Select
Male
Female
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children:
Coverage Requested:
Please Select
E - Employee Only
ES - Employee & Spouse
EC - Employee & Child(ren)
FF - Full Family Coverage
Current Health Issues:
Submit
Should be Empty: