A medical insurance plan by which employees and their dependents or other homogeneous group, are insured under a single policy, issued to their employer or group with individual certificates given to each insured individual or family unit.

Please take a moment to answer the following questions. Remember, this information is needed to find the best agent with the best rate for you, so please answer it as accurately and completely as possible
General Information:

 
1.  *First Name:  
2.  *Last Name:  
3.  *Phone:  
4.  *Email:  
5.  Address:  
6.  Address:  
7.  City:  
8.  *State:  
9.  *Zip Code:  
9.  County:  
The following questions concern the type of business insurance coverage you are requesting . Please answer them as accurately as possible.
1) What is the total number of employees you wish to cover?
2) Description of the business:
3) What type of entity is your company?
4) Please indicate the state in which your business is located:
5) What is the date of incorporation? MM/YY
6) Please indicate your total number of full-time employees:
(If Sole Proprietor enter 1)
7) Please indicate your total number of part-time employees:
(If none please enter 0)
8) Please indicate your total annual revenue:
Please tell us about your health insurance needs.  
9) Do you currently have group health Insurance? Yes No
10) If you answered "Yes," please select your current insurance carrier:
11) If the company is not listed above, please provide the company name here:
12) Current plan type:
13) How many years have you had coverage with this company?
14) How many years have you had continuous coverage (with no lapse)?
15) If you do not have coverage please indicate when you would like a policy to go into effect:
16) What type of plan are you interested in? HMO (Health Maintenance Organization)
POS (Point-of-Service)
PPO (Preferred Provider organization)
Not Sure
 
17) Please choose the preferred co-pay amount:
18) What deductible amount do you want?
19) Coinsurance Option:
20) Would you like to offer prescription drug benefits? Yes No
21) Will it include dental coverage?
22) Will it include vision coverage?
The answer to these basic questions will help us process your information and ensure that our search delivers the most competitive quote for your health insurance policy.
23) Best Time To Contact:
24) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

 

 
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