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Group Insurance - Quote Request / Census Form
To receive a FREE, no obligation quote for Group Employee Benefits, please complete the form below. For groups over 20, or for groups requesting life and/or disability coverage, please print and complete the Proposal Request Form and fax it to us at 352-479-0949.
Need Help? 888-479-0490
Please complete as accurately as possible. Final rates are based upon actual enrollment of plan inception.
Company Name:
Contact's Name:*
E-Mail Address:*
Type of Business:
Physical Address:
City:
State:
Zip/Postal Code:
Phone:
Fax:
What type of insurance are you looking for? Medical Dental Other:
Current Medical Carrier:
Indicate none if none.
Plan Name or Design:
Current Dental Carrier:
Renewal Date:
Employer Pays:
% of Employee Premium
% of Dependents Premium
Intended Effective Date:
Will a Sec125 Plan Be Available?
No Yes
Questions or Comments
Please complete for each employee
Name (first name is fine)
Gender
Employee Date of Birth
Residence Zip Code
Type of Coverage
Spouse Age or DOB
# of Children
1
Employee Name
Gender select M F
Date of Birth
Zip Code
Select Type of Coverage Employee Only Employee + Spouse Employee + Child(ren) Employee + Family Waived
Spouse Age
#Children
2
3
4
5
6
7
8
9
10
11
12
13
14
