Your employee's health is important for the success of your business. So providing a quality health insurance plan is a smart investment. Call us today for an employee benefits evaluation, or complete below and an agent will contact you. We represent many fine companies such as Blue Cross/Blue Shield, Aetna, Unicare, and Humana.

* Required Fields

General Information
Company Name * Contact Name *
Business Description*
Address *
City * , Zip Code *
Phone Number * - - Best day and time to call
Email Address*
Group Information
Total # of Full Time Employees*
Waiting Period
Employer Contribution*
Coverage Information
Major Medical
Life Insurance*
Ancillary
Short Term Disability
PPO HMO
Dental Vision None
Preferences (Check all that apply.)

Our group would like an extensive network of doctors and hospitals.
Our group would like to save money by having a more limited network.
Our group would like to save money by having a High Deductible Savings Account plan.
Our group is interested in setting up a Cafeteria Plan for our employees.
Current Insurance

Company Expiration Date (mm/dd/yyyy)

Reason Looking

Employee Census (use remarks for more than 10 employees)

 
Employee Name*

Birth Date*
(mm/dd/yyyy)
Gender*
Coverage*
Zip Code*
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Remarks / More Employees:

Groups consisting of less than 50 employees are medically underwritten by the insurance company. The quotation that we provide you with are standard rates. These rates are subject to adjustments which are determined by the insurance company upon submission of the application.