Group Insurance Quote

Submitting Agent Name (If applicable):

Company Information
Company Name:
Address:
City:		State: Zip:
Phone #:		Fax:
Contact Person:
Email Address:



Company Structure
Nature of Business:
Business Org. Type:	LLC S-Corp C-Corp Partnership Sole-Prop.
	SIC Code:
Months in Business
Full time EE's
Part time EE's
(If in business less then 6 months, then the group will not be guarantee issue)



Company Current Plan
Commission EE's		1099 EE's
Out of State EE's?	Yes No	Where?
Rate Change Pending?		Anniversary
Current Rates:	EE's	DEP
(Can be obtained from most recent bill)

COBRA EE's?		Ending Dates COBRA
# of Pregnancies: (How Many? When Due?)

Known Health Conditions?
(Duration, Medication, Type, Dosage, Diagnosis, Prognosis)

Current Carrier?	# Years w/ Current Carrier?

What do you like about your current plan?

What do you dislike about your current plan?




How would you like to receive the quote?
by e-mail by fax by mail