Street Address:      City: State: Zip:

Telephone #:     FAX #:     E-mail:

Total number of employees?       Total number of eligible employees? 

Name of your present Group Health Carrier?

 Dental? Vision?    Renewal date?

Use this area to paste your census or list your employee:.... please include any additional information on the type of coverage or specific company that you are looking for:

For each employee, spouse, and child please provide: Name, Birth date, Gender, Zip code.  

For Example

1.) Joe Green 6/23/1967

2.) Bill Brown 5/12/1956, Wife Judy 05/14/1954, son Elroy 04/15/1988,daughter Joni 02/11/1989. son Bob 06/07/1999.

3.) Joan White 06/15/1955, DP Alice 02/14/1957, son Ed 09/11/2002, son Sam 11/11/2004

This form is not an application for health insurance and submitting it places you under no risk or obligation.  The information you provide to us will be used only for the purpose of helping you find health insurance coverage.