Request Medical Quote

Company Name:

Company Information:

Type of Business:

Contact:

Years in Business:

Number of Locations:

Number of FT/PT Employees:

Address:

City:

Zip:

Phone:

Email: *

Current Plan Information:

Carrier:

Rate:

Renewal Date:

Current Plan Benefits:

Medical

Dental

Drug

Vision

Employer Pays: % For Employees

Employer Pays: % for Dependents

Number of FT Employees:

Number of PT Employees:

Number of PT Covered:

Please provide information regarding each Employee working 20+ hours per week.

Proposed Effective Date:

Is this group covered by COBRA Benefits?:

How many?:

Current Rates:

Please include renewal rates - if known

Are any members in the group currently pregnant?:

If Yes, then how many?:

Has any member of the group filed a claim in excess of $5,000 in the past twelve months?: If yes, please include diagnosis and prognosis.:
Are any members of this group currently disabled or handicapped?
Are there any members of the group currently anticipating surgery?
Has any member of this group ever been diagnosed with HIV/AIDS, Cancer, Diabetes, Hepatitis, Multiple Sclerosis, Congestive Heart Failure, COPD, or any other chronic conditions?

Thank you for taking the time to complete this form.

HR & PEO Services