We Are Happy To Provide You With The Best Employee Benefits!

Please complete the requested information in order to receive your FREE, NO OBLIGATION quote.

Company Name
Contact Name
Contact Phone
Contact Email
Company Address
Company City, State, and Zip
Company County
Current Carrier, and Renewal Date

Please choose your coverages:

Deductible:

$250

$500

$1000

$1500

$2500

Co-Insurance:

Plan C

(70/30)

Plan D

(80/20)

100/90/70

90/80/60

Plus

Other Co-Insurance:

Plan Type:

PPO

POS

POS
Open Access

HMO

HMO
Open Access

Indemnity

Office Visit Co-Pay:

$10

$15

$20

$30

Other Co-Pay:

Prescription Plan:
Yes No

Hospital Co-Pay Rider:
Yes No

Co-Insurance Max:
$5,000 $10,000

Other Co-Insurance Max:

Dental:
Yes No

Life Insurance:
Yes No

Disability Insurance:
Yes No

Please complete the following regarding your employees. Please use these indicators for the Dependent Status: S = Single, P/C = Parent/Child(ren), H/W = Husband/Wife, F = Family, W = Waiver. If you have more employees than the 25 spaces offered below, please check below and we will contact you regarding the additional information: I NEED ADDITIONAL FORMS.

	Sex ( M/F)	Date of Birth	Dependent Status	Salary	Zip Code
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
Employee 6
Employee 7
Employee 8
Employee 9
Employee 10
Employee 11
Employee 12
Employee 13
Employee 14
Employee 15
Employee 16
Employee 17
Employee 18
Employee 19
Employee 20
Employee 21
Employee 22
Employee 23
Employee 24
Employee 25

Thank you for your inquiry. We know you will be very happy with our insurance package!