Home
•
Request A Quote
•
Testimonials
•
Forms
•
Links
•
Our Companies
•
Info Center
Request a Group Health Quote
Employer Information
Employer (Correct Legal Name):
*
Telephone Number:
*
Authorized Company Representative (Name and Title):
*
Street Address:
*
City:
*
State/Province:
*
Zip/Postal Code:
*
Small Employer Reform Acceptable Group Assessment
Does your company file taxes in this state/province:
*
Yes
No
Please explain:
Did you employ an average of 2-50 persons (include owners and partners):
*
Yes
No
Did the employees work at least 20 hours per week during the preceding calendar year:
*
Yes
No
Are at least 75% of all eligible employees, after waivers, applying for health coverage:
*
Yes
No
Waivers would include, Medicare (Parts A&B), MCHA, Medical Assistance or General Assistance Medical Care
Is there an employer-employee relationship:
*
Yes
No
Will the employer contribute 50% or more of the employee cost of health coverage:
*
Yes
No
Coverage Information
What coverage information are you interested in:
Medical
Dental
Short Term Disability
Long Term Disability
Long Term Care
Vision
Life Insurance
401K
Cafeteria Plan
Other
Use the "ctrl" key when choosing multiple coverage.
Please describe:
We'll contact and provide you a census form to complete
I accept the
Terms and Conditions
Username or e-mail:
*
Password:
*
Create new account
Request new password
About Us
FAQ
Business Insurance
Life & Health
Personal Insurance
