Group Health Quote General Business InfoStep 1 of 3About YouFirst Name *Last Name *Email *Company Name Address Please include your street address, city, state, and zipCounty Phone number where you would like to be contacted Best time to reach you? Select OneAMPMAnytimeNature of Business Legal Structure of Business Select OneCorporationPatrnership5 CorporationSole ProprietorOtherCurrent Medical Carrier Current Monthly Premium Plan Type Select OneHMOPPOMulti/OptionDoes your group currently have a dental plan? Select OneYesNoName of Dental Carrier Employee InfoNumber of eligible employees Number of part-time employees Out-of-state employees? Select OneYesNo(If yes, please complete out-of-state census)Employee Costs (% to be paid by employee)Dependent Costs (% to be paid by employee)Census InfoEmployee #1 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #2 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #3 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #4 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #5 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #6 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #7 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #8 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #9 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #10 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #11 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #12 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #13 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #14 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #15 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #16 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #17 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #18 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #19 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #20 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #21 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #22 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #23 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #24 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Employee #25 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Out-of State Census InformationOut-of-State Employee #1 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Out-of-State Employee #2 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Out-of-State Employee #3 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Out-of-State Employee #4 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Out-of-State Employee #5 Full Name Sex Select OneMaleFemale# of children Home Zip Spouse Select OneYesNoOn Cobra? Select OneYesNoLife Amount Comments / Questions EmailPreviousNextSubmit
