Contact:

Your Name:

E-Mail:

Business Information:

 

Name of Business
 

Type of Business

City, State

,

Zip Code

County (not country)

Phone (area code first)

Number of Full Time Employees:  

Coverage Profile:

Does your firm currently offer a Group Health Plan?

No Yes  

Does your firm carry Workman’s Comp?

No Yes  

Name of Current Carrier

Reasons for Dissatisfaction with existing plan
(use CTRL to select multiple reasons)

Bad Plan Design Price Increases Slow Claims Payment Expenses Not Covered Customer Service Other None of the Above  

Month of Renewal for existing coverage

Not Sure January February March April May June July August September October November December  

Coverage Desired:

Types of Coverage being considered
(use CTRL to select multiple types)

PPO HMO Dental Disability  

Additional Comments

Please provide additional specific information about your group that will help us recommend a medical plan to meets your needs and budget.  Include any brief information about preexisting conditions that you might be concerned about getting coverage for.

Submit

Thanks!

Within the next 2-3 business days we will either ask for additional information or e-mail price and summary information to the address provided.  You are welcome to provide additional information about your needs by completing the brief survey below.

Census
(OPTIONAL)

This brief census of employees can help us refine our recommendations for your business.  We suggest completing it if your business has 12 or fewer employees.

The Coverage Codes are as follows:

• EE = Employee Only
• ES = Employee and Spouse
• E”#”C = Employee and # of Children
• ES”#”C = Employee, Spouse and # of Children
• Life = No Medical

	Gender	Age	Coverage
1	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
2	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
3	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
4	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
5	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
6	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
7	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
8	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
9	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
10	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
11	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C
12	Male Female		Life EE ES E1C E2C E3C ES1C ES2C ES3C