Health Insurance Group Quotes Arizona

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Group Quote Request

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: