Group Benefits Quote
Contact Information
*Indicates a required field.
  *Company Name:
  *First Name:
  *Last Name:
  *Address:
  *City:
  State: WASHINGTON
  *Zip Code:
  *Work Phone:
  Alternate Phone:
  *Best time to contact:
  *E-mail
General Information
Type of Company?
Do you currently have Business Group Health? No Yes
  If yes, when does it renew?
  Name of current carrier
  Description of Business:
Number of Locations:
*Number of Employees:
  Number of Employees currently covered:
Current Plan Information
Type of Health Plan:
 

Current Deductible:

Other:
 
Current Co-Insurance
Percentage:
Other:
 
Office Visit Co-Pay? No Yes If yes, co-pay amount
Prescription Drug (RX) Co-Pay? No Yes If yes, co-pay amount
Dental Plan In Place? No Yes
Want Dental?
Yes No
Vision Plan In Place? No Yes
Want Vision?
Yes No
Section 125 / Cafeteria / Premium Only Plan In Place? No Yes  
*Voluntary Benefits (employee paid) In Place? No Yes
Want Voluntary Benefits?
Yes No
 
Employer Contribution Percentage for Employees?
Other:
 
Employer Contribution Percentage for Employee Dependants?
Other:
 
Additional Comments, Questions?
 
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