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Proposal Request Form for Individual and Families
Group Health Plan (2 or More employees)




This process enables you to request a group health insurance quote. Please print and complete and submit the health plan options, business information, and group census.



Click here if you have more than 10 employees

Health Plan Options

Choice Of Plans:

   
Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
Health Savings Account (HSA)
Deductibles:
$250 $500 $1000 $1500 $2500 $5000
Doctors Office Visit Copay:
Yes No        
Prescription Drug Card:
Yes No
Co-Insurance Options:
100%/80% 90%/70% 80%/60%
Optional Benefits:
Maternity (Paid as any other sickness)
Dental Insurance
Life/AD&D
Disability Insurance
   


Business Information

Business Name:
Email:
Street:
City / State: ,
Zip Code:
Business Phone:
Fax:
Contact Person:
Association Name: (if applicable)
Member I.D. (I.D.not required to obtain a quote)
SIC Code or Description of Business:
Requested Effective Date:

Total Number of Employees:
(Please complete the following employee information)

Group Census
 

  Employee
Name
Date of Birth
mm/dd/yyyy
Gender
M or F
State Employee
Resides In
Coverage
Employee (EE)
Employee/Sp (ES)
Employee/Ch (EC)
Family (EF)
1
2
3
4
5
6
7
8
9
10
 

 


This process does not constitute an offer of insurance and the quote provided is for illustrative and informational purposes only. Actual rates are subject to changes in demographics and overall health status of your group.


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