Group Health Insurance

Contact Information
Company Name*
First Name*
Last Name*
E-mail*
Address*
City*
State*
Zip*
Phone (day)*
Fax
Group Health Insurance Questionnaires
Your Business is*
Do you currently have Business

Group Health Insurance?
If “Yes”,

when does your current policy expire?
Insurance Carrier you are currently insured with?
Type of Business
Description of Business Operations
Number of Locations
Number of Employees
Exact number of Employees*
Type of Plan*
Current Plan Benefits (explain briefly)
Other Details

To Be Contacted*
Preferred time to contacted?
Additional Group Health Insurance Information – comments/ issues?
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