APPLICATION FOR GROUP HEALTH / MEDICAL INSURANCE

Please Answer All Questions. When form is complete click the Submit button at the end.

1.   APPLICANT INFORMATION

a.Full name of Applicant Company:      

b.Principal Office Address:   Address:    City: State: Zip:

c.Address of Branch Office: Address:   City:   State:  Zip:

d.Number of Employees: Fulltime    

e.   Corporation        Partnership        Individual            Other       

Contact Name:      

Business Phone: - -   

Email Address:   

Fax - -   

Brief Description of Business:

Please Complete the following for each eligible Employee:
Please indicate if you seek a qoute for:
Prescription Drug Plan
Dental plan
Vision Plan
If you currently have a Health plan , please indicate the type.
HMO
PPO
POS
Other