Information about your company or business... * Organization:
Sole Proprietorship Partnership
Corporation LLC Association
* Does your business currently have group health insurance?Yes No
If YES, expiration date of current policy?
If YES, who are you currently insured with?
* What type of business are you in?
* Describe what your business does:
* How long have you been in business?
* How many offices do you have?
* How many employees do you have?1 - 5
6 - 10
11 - 20
21 - 50
50 - 75
75 - 100
100 and above
* What plan type are you interested in?
HMO
PPO / POS
Major Medical
Not Sure
* What is your company's average annual gross revenue?(If you're a new company and the revenue is zero, indicate "new company")
* Most recent calendar year gross payroll?(If you're a new company and the payroll is zero, indicate "new company")
* Tell us if you think you're going to want any optional additional coverages (for example, in addition
to group health, do you think you might want group dental, group disability, group life, group long term care, etc...if you're not sure, just leave blank)
Preferred Contact Time:Morning
Afternoon
Evening
Contact me whenever you want
Additional Comments or Questions?
