Creative Solutions
for Business.
 
In order to provide you with a quote on your Small Group (under 25 employees), please complete the following information.  If you are interested in a quote for your company and there are over 25 lives, please contact us direct.  
Company Name  
Address  
City  
State  
Zip Code  
County  
Contact Name  
Contact Email Address  

Nature of Business  

Years in business  

SIC Code  

# of employees  

Requested Effective Date  

What are the TWO most important factors when choosing health insurance? Price
Type of plan & benefits
Doctor/Hospital provider network
Specific Insurance Company
Your personal relationship with an agent
Other:

CURRENT RATES

EMPLOYEE DEPENDENT

Current

Renewal

Employer Contribution

% %

About your current health plan...

Current Carrier  
Years with them  
If less than 1, prior carrier  
Type of Plan  
Deductible  
Co-Insurance   TO
Drug Card  
Office Visit Copayment  
Supplemental Accident  
Dental  
Vision  
Short Term Disability  
Long Term Disability  

To the best of Employer knowledge on available information, is any employee or dependent:

Currently Pregnant
If Yes, expected date of birth
Currently disabled or hospital confined
If Yes, please explain
Received treatment for cancer, heart, stroke, diabetes, kidney disorder, immune system disorder, psychological, alcohol or drug disorder
If Yes, please explain
Have there been any claims in excess of $5,000 over the past year
If Yes, please explain
Is anyone on COBRA
If Yes, please give names and qualifying dates

Finally, we need your census information:

EE # Employee Name EE DOB EE Status*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Submission of this form is for quoting purposes only.  You will be sent a confirmation that the form has been received and we will begin processing your request.  The quoting process can take up to 3 weeks and we will be in contact with you to advise of the ongoing status.