Group Health Research Form

Complete the form below and we will begin the process of researching options for your company.

If you are looking for individual health insurance, use our Individual Research Form.

630.690.7733 office
630.690.5799 fax

 

 

Group Health Insurance quote form:

Please fill out completely .

Address 1
Address 2
City
State
zip code
Phone
Type of Business
Current Medical Carrier
Renewal Date
Deductible
Coinsurance (90/70, 80/60 etc.)
Office copay
RX card
Type of Plan (HMO, PPO, HSA etc.)
Group
Premium Total
List any known medical conditions

 

 

 

Instructions:
For type of coverage indicate Employee Only (EE), Employee and Spouse (ES), Employee and Child or Children (EC), Employee/Child or Family (EF).
For Location, if employee lives in another state please give state and zip code.

 
Sex of
employee
Date of Birth or Age
Spouse Date of Birth or Age
Type of Coverage
Number of Dependents
Location