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:
-----Select-----
2-5 employees
6-9 employees
10-19 employees
20-29 employees
30-49 employees
50 or more
Number of Employees currently covered:
Current Plan Information
Type of Health Plan:
-----Select-----
HMO
POS
PPO
MSA / HSA / HRA
Not Sure
Current Deductible:
-----Select-----
$250
$500
$750
$1000
$1500
$2000
Other:
Current Co-Insurance
Percentage:
-----Select-----
90/10
80/20
70/30
60/40
50/50
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?
-----Select-----
50%
60%
70%
80%
90%
100%
Other:
Employer Contribution Percentage for Employee Dependants?
-----Select-----
0%
50%
60%
70%
80%
90%
100%
Other:
Additional Comments, Questions?
How did you hear about us?
Select One
Website
Email
Friend
Internet Search
Other
To help keep spamming to a minimum, please enter the word(s) you see into the box below before clicking SUBMIT:
>>>Enter above word(s) here:
