GROUP HEALTH QUOTE FORM
PLEASE FILL IN ALL INFORMATION SO WE CAN PROVIDE YOU WITH THE BEST PRICE.
CONTACT INFORMATION
| First: | Middle: | Last: | |||
| Email: | Phone: | Fax: | |||
| Street Address: | |||||
| City: | State: |
Zip: |
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Preferred Contact: |
Please Contact: |
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NOTE:
A Group Health Insurance Policy quote takes longer and requires more information than other policy types. Filling out the information below and having a recent bill and a census of the currently insured members of the group onhand when contacted will greatly shorten the time it takes to provide you with a quote. |
GENERAL GROUP INFORMATION
| How is the group currently funded?: | |
| How many will be insured?: | |
| Has the group had any chronic or major health problems in the last five years? | |
| Describe: | |
| Other Comments: |
Thank you for your time in completing this questionnaire.
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