Type of Business Type of Business: Standard Industry Code (if known): # of Full Time Employees:         # of Part Time Employees: Give a complete description of any type of hazardous/ dangerous duties performed by your employees:

Current Group Health Insurance Information Carrier (Company) Name (not agency): Please give a brief description of your current Group Health plan:

Benefits Desired Major Medical Deductible: $200 $250 $300 $500 $1,000     Optional Pregnancy Coverage: yes   no Dental Coverage: yes   no Supplemental Accident Coverage: yes   no Disability Insurance: yes   no PCS Card: (Prescription Discount Option) yes   no Group Life Insurance: Amount: yes   no $ PPO Option: yes   no HMO Option: yes   no

Employee Information Please list all employees you wish to cover: Employee Name Date of Birth Age Sex Dependent Status Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or email an additional listing.

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

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