Group Health Quote

Name *

Address

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Email *

Company Name

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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?

1 + 1 = ?Please prove that you are human by solving the equation *