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.


GENERAL INFORMATION
Legal name of business:
Contact name: 
Address: 
City:
State:
Zip code:
Business phone:  
Best time to call:
Contact E-mail address:  
TYPE OF BUSINESS
Type of business:  
Standard industry code (if known):
Number of full-time employees:
Number of part-time employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees: 
CURRENT GROUP HEALTH INSURANCE INFORMATION
Carrier (Company) Name (not agency):  
Please give a brief description of your current Group Health plan:
BENEFITS DESIRED
Major medical deductible:
Optional pregnancy coverage:
Yes No
Dental coverage:
Yes No
Supplemental accident coverage:
Yes No
Disability insurance:
Yes No
PCS card:
(Prescription discount option)
 Yes No
Group life insurance:
Yes No
PPO option:
 Yes No
Amount:
$
HMO option:
Yes No
EMPLOYEE INFORMATION
Please list all employees you wish to cover:
Employee name:
Date of birth:
Age:
Sex:
Dependent status:
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
Male Female
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments below or indicate that you will fax or email an additional listing.
ADDITIONAL COMMENTS
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.
Are you a citizen of the United States? 
Yes No
Have you lived outside the United States 
during the last 3 years? 
 Yes No
Do you plan to leave the United States for travel or
residence during the next 3 years? 
Yes No
Please list the foreign countries that you are
planning to visit / reside:
Do you currently work in a hazardous occupation? 
Yes No
Do you participate in any risky outdoor activities?
 Yes No
Do you fly as a pilot, co-pilot
or crewmember of an aircraft?
 Yes No
Are you an active member of the
military or military reserve?
 Yes No
Have you received three or more moving violations or had your driver's license suspended/revoked in the past 5 years? 
 Yes No
Have you been found guilty of reckless driving
or driving under the influence (DUI/DWI)? 
 Yes No
When was the last time that you used any type of
tobacco product or nicotine substitute? 
Is there any family history of cardiovascular disease
before the age of 60? 
Yes No
Have you had any health symptoms or been treated for any of the conditions listed below? 
Yes No

If Yes, please check those below which apply:
AIDS & AIDS related Epilepsy Liver disease Psychiatric disorders
Alcoholism Fatigue disorders Lupus Rheumatoid arthritis
Alzheimer's Heart Disease/
Bypass surgery		 Lymphoma Seizure disorders
Asthma High blood pressure Manic depression Spinal disc disorders
Breast cancer HIV Melanoma Stroke
Chronic bronchitis Infertility Multiple sclerosis Substance abuse
COPD Joint replacement Muscular dystrophy TIA
Diabetes Kidney stones Other debilitating disorders Ulcerative colitis
Emphysema Leukemia Peripheral vascular disease Uterine disorders
Do you have cancer?
Yes No
If yes, specify cancer details here: 
COVERAGE INFORMATION
Coverage amount?
Deductible:
Quote requested within:
 24 hrs 48 hrs 72 hrs 120 hrs
Do you want an umbrella quote?
 Yes No

Quotation Forms


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