B.1.a Request a Group Quote
Delivering insurance value ... a cut above.

Group Coverage Quote Request Form

To receive a free, no-obligation quote for your business, simply print out this form, complete, and fax to us at 425-329-2019.

Note: Your information is protected by HIPAA guidelines and is never sold to third parties.

What type of coverage are you looking for? Check all that apply.
[ ] Health [ ] Dental [ ] Life [ ] Disability
Company:
__________________________________________________________
Contact:
__________________________________________________________
Address1:
__________________________________________________________
Address2:
__________________________________________________________
City:
____________________________ State:_________ Zip Code:__________

Phone:
____________________________ Fax: ____________________________
Email:
____________________________ Preferred contact method:
[ ]Phone [ ]Fax [ ]Email
For Health Insurance Quotes Only
Do you currently have group coverage? ___________
If no, continue to Employee Census information.
Carrier Name:
_____________________________________________________
Total Monthly Premium:
______________________
Deductible Amount: ______________________
Office Visit Co-Pay: ______________________
Rx Co-Pay:
(1) _______________ (2) ______________ (3) _______________

Renewal Month:
_____________________
Your Employee Census Information
  Name Gender Date of
Birth
MM/DD/YYYY		 Enroll
Spouse?		 Spouse Date of
Birth
MM/DD/YYYY		 Enroll Children?
1   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
2   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
3   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
4   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
5   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
6   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
7   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
8   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
9   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
10   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
11   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No
12   [ ]Male
[ ]Female		   [ ]Yes [ ]No   [ ]Yes [ ]No


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