Company Group Insurance Questionnaire
Thank you for reaching out to Seto Health Group. To best assist you, please fill out the following information to guide you to suitable plan options. Thank you for your cooperation.
Today's Date
Contact Information
Name
*
First Name
Last Name
Title
Company Name
*
SIC Code
Company Website
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work/Direct Phone Number
*
E-mail Address
*
Do you currently offer a group health insurance plan?
*
Yes
No
Current Insurance Provider (if applicable):
Open Enrollment Period
-
Month
-
Day
Year
Date
Please Upload The Company Census
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Are you interested in transitioning eligible employees to Medicare?
*
Yes
No
Schedule An Appointment
If you have already scheduled an appointment, please proceed without repeating the process.
Please provide any additional information or questions you may have:
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