Group Health INSURANCE

At NEC Insurance Agency, Inc. We put the power of the internet to work for you! Please take a moment to answer the following questions. Remember,this information is needed to find the best the best rate for you, so please answer it as accurately and completely as possible.

Requested Coverage Type

1) What is the total number of employees you wish to cover?

2) Please provide current insurance:

3) Please provide current deductible:

4) Please provide current premium:

5) What type of plan are you interested in?

6) Please choose the preferred co-pay amount:

7) What deductible amount do you want?

8) Coinsurance Option:

9) Would you like to offer prescription drug benefits?  Yes No

10) Will it include dental coverage?  Yes No Not Sure

11) Will it include vision coverage?  Yes No Not Sure

Please answer these last few questions, and we'll begin our search for the most suitable insurance policy for you.

1) Best Time To Contact:    

2) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.


The answer to these basic questions will help us process your information.

Do you own or rent your residence:  Rent Own Other

1. First Name:     

2. Last Name:      

3. Phone:              

4. Email:               

5. Address:          

6. Address:          

7. City:                   

8. State:                

9. Zip Code: