* Company Name:
* Contact person:
Address:
City: State Zip:
* Phone #:       Home Phone #: 
FAX #:
E-mail address

Type of business
Business location:  City State Zip
Number of full time employees
How did you find out about this site?

What are you looking for in a group health insurance plan? Check all that apply:

Group health insurance for business 
HMO
Dr. visit co-pay
Maternity
Prescription card w/ co-pay
Point of Service (POS)
Preferred Provider Plan (PPO)
I Want to Avoid an HMO
High Deductible Group Health Insurance
     (usually $1,500 to $5,000 deductible for hospital/surgical)

I am interested in getting quotes/information on the following subjects. Check all that apply:
Group Life Insurance - 
                                How much insurance (face amount)
                                For whom?
Group Dental
Group Disability (Income protection)
Group Long Term Care (could be tax deductible) (Nursing home and at-home care)
SEP IRA or 401K (Before tax long term retirement plans)

Persons to be insured: (Please list all to be included in the insurance plan)
(Must be at least 30 hrs per week)

How would you prefer to be contacted? Check all that apply.

Email   Fax  Mail   Work Phone  Home Phone

Best time to call?
Do you currently have medical insurance? Yes No
Name of current Insurance Company?
How much do you currently Pay?
Why do you wish to change?
How soon do you need insurance?

   Note: that the deadline for group insurance is usually the middle of the previous month
   ie: March 14 for April 1 start date

Any other comments or questions