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> Group Health Insurance

To request free quotes for Group Health Insurance please take a moment to provide us with some basic information about your service requirements.

Do you currently offer group health insurance benefits to your employees? [required]

	Yes
	No
	If Yes, please provide the plan's expiration date:

If you do currently offer group health benefits to your employees, what types of coverage options are available? [required]
(Check all that apply)

	HMO
	PPO
	POS (Point of Service)
	Unknown
	Other
	If Other, please describe:

How many total employees does your organization currently have? [required]
Include employees at all locations.

Please indicate the exact number of employees who will be covered by group health benefits: [required]
NOTE: Count only eligible employees, not their spouses or dependents.

Which of the following best describes your industry? [required]

In what zip code is your office located? [required]
Please use the 5-digit zip code.

How long has your organization been shopping for group health benefits? [required]

Please indicate the health plan options in which your organization is interested (if any): [required]
(Check all that apply)

	None - would like assistance evaluating options
	HMO
	PPO
	POS
	Mini-Med
	Self-Insure
	Other
	If Other, please describe:

Please provide your preferred email address. [required]

10)

Health Census: Please take a moment to complete the following census for each employee if there will be 5 employees or less enrolled in the group health plan. Be sure to complete all fields for each employee. [required]
If you have more than 5 employees the provider will contact you directly to obtain the census information.

	Employee Zip	Gender	Age	Coverage
Employee
Employee
Employee
Employee
Employee

11)

Please explain any further requirements you would like our providers to be aware of when reviewing your request.
(1,000 character limit)

Once you've answered all of the required questions above simply click on the "Complete" button below to verify your contact information and submit your quote request.

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