Group Coverage

GROUP INFORMATION (Unless specified, all information is required to process) *NOT Required
Full Legal Name
Contact Name
Phone
Fax	*
E-mail
Street Address
City
State
Zip

Type of Business
Years in Business

Employee Information (If any of the following are not applicable, please enter "0")
Total Number of Employees
Part-time Employees
Employees in Waiting Period
Employees Waiving Coverage
Employees with Other Coverage
COBRA Participants		Enter "0" if n/a	Please list the name and effective date(s) for each former employee's COBRA coverage (enter "0" if not applicable):	1) 2) 3)	*
Enrolling Employees	- Each enrolling employee will need to complete a health questionnaire (click here - new window will open)

Current Benefits* (Required only if you currently have medical coverage for your group)
Type pf Plan	If you do not have existing coverage for your group, please enter "none" and press "Submit" below
Office Visit Co-pay
Hospital Co-pay
Prescription Co-pays	Generic Brands Name Brands Non-Formulary / Specialty

Carrier Information* (Required only if you currently have medical coverage for your group)
Current Health Insurance Carrier
Years with Current Carrier
Eligibility Waiting Period
Hours Worked to be Eligible
Do You Have Worker's Compensation?
Employer Contribution for Health Premiums	Minimum is 50%
Supplying us with this information does not in any way obligate your group to enroll, nor is there any cost associated with this part of the process. The information simply allows us to start the process of requesting a quote.