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? ---HMO (Health Maintenance Organization)POS (Point-of-Service)PPO (Preferred Provider organization)Not Sure

6) Please choose the preferred co-pay amount: ---$5$10$15$20$25Not Sure

7) What deductible amount do you want? ---$500$1000$1500$2500$5000$10000Not Sure

8) Coinsurance Option: ---100%90%80%Not Sure

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:    ---AnytimeMorning at HomeMorning ati WorkAfternoon at HomeAfternoon at WorkEvening at HomeEvening at WorkWeekends

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:                ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

9. Zip Code: