Name *
Address
Address 2
State
City
Zip
Phone Number
Email *
Company Name
Address:
City:
State:
Zip:
Please describe the type of business you operate:
When would you plan on implementing your new health-care plan? During the next monthWithin three monthsBefore the end of the year
How many people will be eligible of the new health-care plan?
What percentage of eligible employees would you expect to particiapte?
What co-payment amount would you like your employees to spend when visiting a doctor’s office? $10$15$20more than $20none
Would you like your employees to have a prescription co-payment card? YesNo
What type of plan would best fit the needs of your employees? HMOPPOPOSTraditional IndemnityHospital & Surgical Only
What amount of hospital deductible is best for your policy? $250$500$1000$1500
What amount of coinsurance is best for your policy? 50/5070/3080/2090/10100/0
Do you want to offer group life insurance? YesNo
Do you want to offer group dental? YesNo
Is there any additonal information you would like us to consider as we process your request?
0 + 7 = ?Please prove that you are human by solving the equation *
These quotes do not guarantee coverage and actual premiums may differ from the quotes provided
