Domestic group health insurance census form

Source Id:
plans

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Group health insurance quote request form

Please provide us as much information as possible for the most accurate quotes and we would be glad to provide you with free and no obligation group health insurance quotes from multiple companies.
The information you provide will be kept strictly confidential and will be used for quote purposes only.
Please note that not all plans are available in all states.

Contact Information

Business Name^*
Type of Business^*	Please try to be descriptive.
SIC Code	Not sure? Search
Address
City
State^*
Zip Code^*
Day Phone
Evening Phone
Fax
Best time to reach you
Email^*

Present Plan

Present Carrier
Renewal Date	mm/dd/yyyy
Worker Compensation Carrier
Premiums	Excellent Good OK Concerned
Benefits	Excellent Good OK Concerned
List of Providers	Excellent Good OK Concerned
Claims Service	Excellent Good OK Concerned
Agent/Broker Service	Excellent Good OK Concerned
Other:	Excellent Good OK Concerned
Other:	Excellent Good OK Concerned

New Plan Preferences

Medical
Prescription Drugs
Maternity
Well Baby Care
Dental
Vision
Short Term Disability
Long Term Disability
Group Life Insurance
Additional Life Insurance
Health Savings Account (HSA)
Preferred plan types: PPO HMO POS Indemnity Self-Insured
(Check all that apply)

Answer the following questions for employees and their dependents. How many proposed applicants have/are:

Number of Instances
	Incurred medical claims of more than $5,000 during the past 12 months? If any, give reasons:
	Within the past 6 months been disabled or hospital confined? If any, give reasons:
	Currently pregnant? If any, give due date:
	Been diagnosed as having or received treatment in the past five years for: a. Cancer or malignancy b. Heart disorder, heart disease or stroke c. Acquired immune deficiency syndrome (AIDS) or AIDS Related Complex (ARC) d. Received treatment for drug abuse or chemical dependency e. Received treatment for alcohol abuse f. Diabetes (Type 1 or Type 2 with insulin or oral medications) Provide details:

Any other comments:

Total Number of Employees^*
Number of Employees Need Coverage^*

Fields with * are required fields.

Health insurance products are provided by licensed insurance agent/broker, Jagruti Khatri.

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