Group Insurance Quote

Submitting Agent Name (If applicable):
 
Company Information
Company Name: 
Address: 
City: State:    Zip: 
Phone #: Fax: 
Contact Person:
Email Address:
   
     
 
Company Structure
Nature of Business:  
Business Org. Type: LLC  S-Corp  C-Corp  Partnership  Sole-Prop.
  SIC Code: 
Months in Business  
Full time EE's  
Part time EE's  
(If in business less then 6 months, then the group will not be guarantee issue)
 
 
 
Company Current Plan
Commission EE's 1099 EE's 
Out of State EE's?   Yes  No Where? 
Rate Change Pending? Anniversary 
Current Rates: EE's DEP
(Can be obtained from most recent bill)
COBRA EE's? Ending Dates COBRA 
# of Pregnancies: (How Many? When Due?)
Known Health Conditions?
(Duration, Medication, Type, Dosage, Diagnosis, Prognosis)
Current Carrier? # Years w/ Current Carrier?
What do you like about your current plan?
What do you dislike about your current plan?
 

   
 
How would you like to receive the quote?
by e-mail  by fax  by mail