If you would like more information, please call (734) 416-8100 or complete the following form.
(
*
denotes a required field)
ABOUT YOU
First Name:
*
Last Name:
*
Your Title/Position:
*
Your Email Address:
*
BUSINESS INFORMATION
Company Name:
*
City:
*
State:
*
Select a State
Alabama
Alaska
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
North Carolina
North Dakota
Ohio
Oklahoma
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
West Virginia
Wisconsin
Wyoming
Zip Code:
*
Country:
*
Phone Number:
*
Best Time to Contact:
*
Select...
AM
PM
Evenings
Nature of Business:
*
(e.g. - machine shop, lawyers...)
Number of Employees:
*
(full time only - 30+ hours)
CURRENT INSURANCE SITUATION
Does your company currently offer group health insurance?
*
Select...
Yes
No
If you do not currently offer coverage, you do not need to answer the next 4 questions. You can use the CTRL key to make multiple selections.
Name of Current Insurance Carrier:
Types of insurance currently offered:
PPO
HMO
Indemnity
Hospital/Surgical Only
Reasons for Dissatisfaction with existing plan:
Bad Plan Design
Price Increases
Customer Service
Expenses Not Covered
PPO/ HMO Network
Other
Month of Renewal of Existing Coverage:
Select...
Not Sure
Jan.
Feb.
March
April
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
PLAN PREFERENCES
Use the CTRL key to make multiple selections.
Types of coverage you would like quotes on:
*
PPO
HMO
Indemnity
Hospital Only
Additional Insurance Options Wanted:
Dental
Disability
Vision
Pension
ADDITIONAL COMMENTS
Please provide any additional specific information about your group that will help us recommend a medical plan to meet your needs and/or budget.Include any brief information about preexisting conditions that you are concerned about obtaining coverage for.
By hitting the Submit button
, I hereby acknowledge that the information in this form is true and complete to the best of my knowledge.
THANK YOU!
Within the next 1-3 business days we will either ask for additional information or e-mail price and summary information to the address provided. You are welcome to provide additional information about your needs by completing the brief survey below.
CENSUS FORM:
(EE=employee, ES=employee+spouse, EC-empl+chiild(ren), FAM=family)
Gender
Age
Coverage
Gender
Age
Coverage
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
By hitting the Submit button
, I hereby acknowledge that the information in this form is true and complete to the best of my knowledge.
