Arizona Health Insurance, Group Health Insurance, Employer Insurance, Health Insurance Broker
 
 

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

Census
Name (Optional) Gender Age 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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