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Employer Information

Please complete the following information for a quote.  Thank you.
Employer Name:
Contact Person:
Phone number: Email:
City:

State:  Zip:
Multiple Locations: If yes, please list City or Zip code on census below
Type of business:
Employer Contribution: Employee Only Premium 

        Dependents:

  
Please Note: Majority of health carriers require the Employer to contribute at least 50% of the "Employee Only" premium
Waiting period for New Hires to become eligible for benefits: 
Currently Covered:       Carrier:

Medical Information
To the best of your knowledge

Does Any Employee or Dependent have:      (please check all that apply)
High blood pressure    Pregnant       Immune Disorders    Cancer
Claims in excess of $5,000 within the last 12 months
Hospitalized within in the last 12 months
Disabled

Medical Coverage Requested

Please check all that apply

 HMO  PPO 

Copay:

 $10  $15  $20   $30   $40

Deductible:

 $100   $250   $300   $500   $1,000

Coinsurance:

Additional Coverage Requested
Dental     Pet Insurance     Vision   Life/AD&D:   

Disability (Short/Long Term) 401K  EAP - Employee Assistance Program

Census
Name (Optional) Gender Age/DOB Smoker? Status Health?

Zip Code or City 

(If Different City/State)
If you have a census already prepared, please feel free to email to the following address instead of completing the above census form
 groupquote@abc-incorp.com

Additional information/comments:

 

 

  

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