FAST AND EASY GROUP HEALTH INSURANCE PROPOSAL FOR BUSY PEOPLE

[]

1

FIRST NAMEFirst Name

LAST NAME

BUSINESS NAMEyour full name

Today's Dateof appointment

Mailing Addressyour full name

Unit #your full name

Cityyour city

STATE

CA

ZIPZIP

CELL PHONECELL PHONE#

BUS PHONE

Emaila valid email

Email again for Accuracya valid email

CURRENTLY INSURED? If yes, list carrier and # of years continuous. If no current insurance, type "NONE"

UNDERWRITING INFORMATION

Type of Business

Type of Business?RetailOfficeRestaurantWholesaleMobileArtisan ContractorGeneral Contractor

Bus Structurepick one!

Business Stucture?Sole ProprietorPartnershipLimited Liability CorporationCorporation

# Locationspick one!

Number Locations?012345-1010-2020+

Annual Gross Revenues?Gross Revs

Total Number of Employees?

Total Number Employees?0-22-45-1010-2020+

Total Estimated Annual Payroll?your full name

Please describe exactly what your business does. Describe in full all products, services, and delivery methods your company offers.more details

0 / 250

PLEASE CHECK THE GROUP PRODUCTS BELOW THAT YOUR COMPANY WANTS TO MAKE AVAILABLE TO YOUR EMPLOYEES.

HEALTHDENTALVISIONLIFEST DISABILITYLT DISABILITY

Employee #1 Full NameEmpl #1

M/F ?GENDER

M/F ?MaleFemale

Birthdateyour full name

Age?your full name

Family Statuspick one!

Status?SingleCoupleSingle ParentFamily

Zip Codeyour full name

# Dependentspick one!

# Childen01234567

Cobrapick one!

CobraYesNo

Salaryyour full name

Job Title of Employee ?your full name

Plan Typepick one!

Plan Type?IndividualFamily

Employee #2 Full Name and same information as #1 above.Emp # 2

Employee #3 Full Name and same information as #1 above.Emp # 3

Employee #4 Full Name and same information as #1 above.Emp #4

Employee #5 Full Name and same information as #1 above.Emp #5

Employees #6-20 Full Name and same information as #1 above. List one employee per line.more details

0 / 1500

Do you or any of your employees have any special health problems or insurance needs? List them here. If none type "NONE"

0 / 500

Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for?more details

0 / 500

Any Claims?Please describe in box to the right

YESNO

If there has been any claims, please list the claim date, amount paid, and a brief description of what happened. If you have had no claims, type "NONE".more details

0 / 250

CLICK HERE TO GET MY GROUP HEALTH INSURANCE PROPOSAL

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By clicking the button below you agree to allow our agency to release this information, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. We take your privacy and data security very seriously!

Fileupload

.......................................... Please Upload current Declarations Page or Policy if available ....................................................

Previous

Next