Group Health Insurance Form

 

 

Company Name:    
City: State:
Phone: Zip:
Fax:    
       
Name(s) of CEO/President/ Principal/Partners/Owner(s) if under 20 employees or Controller /Human Resources for 20+:
E-mail address(es) of the above:
       
IMPORTANT: Quotes and unique customized savings strategies take hours of preparation. We've saved groups as much as $6000 per employee per year in health insurance premium savings while showing the employer how the group can obtain the same or better  protection while enabling them to keep most of their tremendous savings! We don't want to waste your time or ours!
       
Choose One:    
       
Please Provide the Following Required Info:
 
Employer contribution %-: (Must be  at least 50% of  employee's cost not including dependents.)
Current group Monthly Premium- : Individual Rate/Month:
Family Rate/Month: Anniversary Date:
Other ie employee+children or employee+spouse rates if applicable:
Exact name of current plan, carrier name  and type  (ie HMO, POS, PPO) -:
Before we provide our census info, we have a few questions. Please call us at your earliest convenience.
Comments:

  

 
Census Information - required to calculate rates
(if more than 50 employees please call)

 

        

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