Donald R. Yert, CEO





Quotation Forms
 
GROUP HEALTH INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.


Company Information
How would you like to receive your quote?:
 Phone Fax E-Mail Mail
If phone, when is a good time to call?:
 AM PM
Company Name :
Address:
City:
State:
Zip:
Company Industry (SIC Code):
Phone:
Fax:
E-Mail:
Requested Effective Date:
 
Current Carrier
Our Current Carrier is:
Our Current Plan Design is:
Current Rates:
Single:
Employee/Spouse:
Employee/Child:
Family:
Renewal Rates:
Single:
Employee/Spouse:
Employee/Child:
Family:

Employee Census
Employee DOB:
 Choose date
Spouse DOB :
 Choose date
Gender:
 Male Female
Active/COBRA:
 Active COBRA
Coverage Type :
No. of Children:
*Salary:
 per
**Occupation:
Medical Conditions:

*Salary needed if quoting Long or Short Term Disability.
**Occupation needed if quoting Long Term Disability.
Employee DOB
Gender
Active/COBRA
Spouse DOB
Coverage Type
Children
Salary
Occupation
2005-10-18 Female Active 2005-10-24 Employee/Child 1 1 1
Medical Conditions : 1
2005-10-24 Female Active 2005-10-31 Employee/Child 2 2 2
Medical Conditions : 2