Group Health Insurance

Group Health Insurance

Request for more information
Name of your Company
As listed on Secretary of state
YesNo
Who is your current carrier
When does your plan renew?

MonthDayYear
Date
When would you like coverage to begin?

MonthDayYear
We’ll review timing and next steps after receiving your information.
Number of Full-Time Employees (30+ hour per week)
How many employees are expected to enroll in coverage?
Most group plans work best when a portion of eligible employees enroll.If participation is a concern, there are options we can review.
Employee Census (Required for Quoting)

Download the employee census template here, complete it, and upload it below.

How it works:

1. Download the census template.
2. Open it in Excel or Google Sheets.
3. Enter one row per covered person (employees and dependents.) Do not add employees who do not need coverage.
4. Save the file.
5. Upload the completed file below.

Trouble opening the file?
If Google Sheets does not open correctly, download the file and open it in Microsoft Excel.
If you do not have Excel, you can still complete the file in Google Sheets and upload it here.
Census

Cancelof
Tax ID Number
Contact

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
When is a good time to review coverage options?
Should be Empty: