Group Health Insurance Quote Form

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Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* All fields required.

General Information
Legal Name of Business:
Contact Name:
Address:
City:
State:	Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
E-mail Address:

Type of Business
Type of Business:
No. of Full Time Employees:	No. of Part Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Health Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:	Premium Amount: $
Years Insured:
Please give a brief description of your current Group Health plan:

Benefits Desired
Major Medical Deductible:		Optional Pregnancy Coverage:	Yes No
Dental Coverage:	Yes No	Supplemental Accident Coverage:	Yes No
Disability Insurance:	Yes No	PCS Card: (Prescription Disc Option)	Yes No
Group Life Insurance:	Yes No	PPO Option:	Yes No
Amount:	$	HMO Option:	Yes No

Additional Comments or Questions

Please click the "Submit Quote" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.

Phone: 678.297.7977 Toll Free: 1.800.378.0766 Fax: 678.297.9575

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