Company Name

Contact

(

)

Ext.

(

)

Email

Address

City

State

Zip

Number of Employees to Quote

Flat Rate (Minimum 50%): $

Employer Contribution per Dependant (Minimum 50%): %

Employer Contribution per Employee: %

How long have you been in business?

What company do you have insurance with now?

Plan Preference

1) ANY 2) HMO 3) PPO 4) POS

1st. Employee Name

Date of Birth(mm/dd/yyyy)

Zip

Dependent Status

1) Employee Only 2) Employee and Spouse 3) Employee and Child 4) Employee/Spouse and One Child 5) Family

2nd. Employee Name

Date of Birth(mm/dd/yyyy)

Zip

Dependent Status

1) Employee Only 2) Employee and Spouse 3) Employee and Child 4) Employee/Spouse and One Child 5) Family

3rd. Employee Name

Date of Birth(mm/dd/yyyy)

Zip

Dependent Status

1) Employee Only 2) Employee and Spouse 3) Employee and Child 4) Employee/Spouse and One Child 5) Family

4rd. Employee Name

Date of Birth(mm/dd/yyyy)

Zip

Dependent Status

1) Employee Only 2) Employee and Spouse 3) Employee and Child 4) Employee/Spouse and One Child 5) Family

5th. Employee Name

Date of Birth(mm/dd/yyyy)

Zip

Dependent Status

1) Employee Only 2) Employee and Spouse 3) Employee and Child 4) Employee/Spouse and One Child 5) Family