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Group Health Plan (2 or More employees)Proposal Request Form for Groups (2 or More employees)




This process enables you to request an individual health insurance quote. Please complete and submit the health plan options and personal information.


Choice Of Plans: Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
Health Savings Account (HSA)
   
Deductibles:
$250 $500 $1000 $1500 $2500 $5000
Co-Insurance Options:
100% / 80% 90% / 70% 80% / 60%
Maternity:
Yes No
Doctor Office Visits:
Yes No
Prescription Drug Card:
Yes No
Dental:
Yes No
Life:
Yes No
Association Name:

Member Information

First Name:
Last Name:
Member I.D. (I.D. not required to obtain a quote)

Gender

Male Female
Date of Birth: (e.g. 01/01/1970)
Street 1:
Street 2:
City:
State:
Zip Code:
Phone Number:
Cell Phone:  
Email:

Do you use tobacco?

Yes No
Height: Feet  Inches
Weight: Lbs.
Spouse Information
First Name:
Last Name:

Gender

Male Female

Do you use tobacco?

Yes No
Date of Birth: (e.g. 01/01/1970)
Children Information

Unmarried - ages 1 through 19 (through 25 if un-married, full time students)

Number of Children    

Age

Gender

Male                Female

Male                Female

Male                Female

Male                Female

Current Insurance Information

Do you currently have health insurance coverage?

Yes No
Current Insurance Company:
Optional Information (Not required to obtain a quote)
Current Monthly Premium:
Current Deductible:
Current Office Visit Copay:
Current RX Copay:
Medical History
Does any insured take medication on a regular basis?  Please explain.
Insured Name Medication

Condition

In the past 5 years, has anyone to be insured had any symptoms, diagnosis, consultation, or treatment for any medical conditions (other than colds, flus, routine exams, etc.)?
Insured Name Diagnosis

Treatment

Is any member of your family pregnant?

Yes No


This process does not constitute an offer of insurance and that the quote provided is for illustrative and informational purposes only.



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