Group Health Coverage Request

1

What's name of your business?

2

Business state/county/zip code?

3

What’s your full name?* This field is required.

First Name

Last Name

4

Where should we send your coverage details?* This field is required.

Email

5

What’s the best phone number to reach you?* This field is required.

6

How many full-time equivalent employees does your business currently have?

8

When would you like your group health coverage to start?

Date

9

Which of the following benefits are most important to your employees?

Medical Coverage

Dental Coverage

Vision Coverage

Prescription Drug Coverage

Mental Health Services

Wellness Programs

Other

10

What is your approximate budget per employee per month for health insurance premiums?

12

Are you currently offering any group health coverage to your employees?

YESNO

13

If yes, please describe your current plan and what you like/dislike about it:

14

When’s the best time for Candace to reach out?

Morning (9–12)

Afternoon (12–4)

Evening (4–7)

Anytime works 🌿

15

By submitting, you agree to be contacted by a licensed agent (Candace Larry) regarding Medicare options. This is a free, no-obligation consultation. Covered by Candace is an independent agency, not affiliated with Medicare or CMS.

I understand and agree.