Group Health Insurance Quote

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* Required information.

General Information

Your Name *
Your Email Address *
Legal Name of Business *
Address *
Adress 2
City *
State *
Zip *
Business Phone *
Best Time to Call
Conover Beyer Agent Name (if any)

Type of Business

Type of Business *
Standard Industry Code If Known

Number of Employees

Full Time *
Part Time
Description of any Hazardous/Dangerous duties

Benefits Desired

Major Medical Deductible
Dental Coverage
Yes
No
Disability Insurance
Yes
No
Prescription Coverage
Yes
No
Vision Coverage
Yes
No
Group Long Term Care
Yes
No
Group Life Insurance
Yes
No
Amount $
PPO Option
Yes
No
HSA/HRA Option
Yes
No
HMO Option
Yes
No

Current Group Health Insurance Information

Carrier Name (not agency)
Describe your current group plan

 

Employee Information – List all employees that work an average of 25 hours a week or more.

Complete below or send separate list.

 

Employee 1

Employee Name
Date of Birth
Age
Gender
Status

Employee 2

Employee Name
Date of Birth
Age
Gender
Status

Employee 3

Employee Name
Date of Birth
Age
Gender
Status

Employee 4

Employee Name
Date of Birth
Age
Gender
Status

Employee 5

Employee Name
Date of Birth
Age
Gender
Status

Employee 6

Employee Name
Date of Birth
Age
Gender
Status

Employee 7

Employee Name
Date of Birth
Age
Gender
Status

Employee 8

Employee Name
Date of Birth
Age
Gender
Status

Employee 9

Employee Name
Date of Birth
Age
Gender
Status

Employee 10

Employee Name
Date of Birth
Age
Gender
Status

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