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QUOTE HEALTH & APPLY ONLINE
Group Health Insurance
* = Required Information
This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Group Health insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
Proper Protection Fact Finding Questions
Of the following, what is the primary reason for quote request? Requesting More Information 
Paying Too Much 
Decrease Work Comp Premium 
Other 
In the order of importance, what is most important to you? Price 
Service 
Proper Coverage 
Approximately when was the last time you did a review with your agent? Within the year 
Over 2 years ago 
Over 5 years ago 
Never 
Would you be interested in combining your commercial insurance for additional savings? Yes      No 
Do you need a group life quote? Yes 
    No 
Reason(s) For Changing Current Insurance Provider?
Has your current company/agent failed to meet your expectations in any way?
What else must I do to earn your business?
 
Contact Information
Contact Name
Business Name
Address
City
State
Zip Code
Business Phone Number
Primary Phone Number To Reach You
Fax
Email *
Contact Me During?
 
Business Information
Is This a New Business Yes     No
Years in Business
Type of Business
Briefly Describe Your Business
More Than One Location Yes     No
If yes, where
Number of Full Time Employees
Any Independent Contractors? Yes     No
Any COBRA participants previously employed by you? Yes     No
 
Current Policy Information
Current Insurance Company
Current Insurance Plan Type
Current Monthly Premium $
Please Fax Us With A Copy of Current Policy Yes     No     N/A
 
Interested Policy Information
Requested Effective Date
What Type of Plan Are You Interested In
Would you be interested in going to a higher deductible & higher out of pocket max to reduce your monthly premium? Yes     No
% of Costs Paid By Employer:   % of Employees Cost

% of Dependents Cost
Employees Living Out of State? Yes     No
Type of Employees to be Quoted: All
Salary
Management
Non-Union
Hourly  
 
Census
Name Gender Birth Date
(mm/dd/yy)
MEDICAL
HMO
or
PPO
or
HSA
DENTAL
HMO
or
PPO
SPOUSE
(Y/N)
Number
of
Children
COBRA
(Y/N)
Home
Zip