... health insurance specialists for a better health insurance value! 
 

 
Group Health Insurance Quote Form
(For small businesses  only)

    Company Name: City,State   
    Zip code:  Company Phone: :Name(s) of
      CEO/President/  Principal/Partners/Owner(s) if under 20 employees  or Controller /Human Resources for 20+)  
     (Required)        
     Email address(es)  of the above (Required)
    
 
IMPORTANT:Quotes and unique customized savings strategies take hours of preparation. We've saved groups as much as $6000 per employee per year in health insurance premium savings while showing the employer how the group can obtain the same or better  protection while enabling them to keep most of their tremendous savings! We don't want to waste your time or ours! Please be ready to place your business through us if we can meet or exceed your health insurance needs and price range. Please be ready to tell us precisely what that is BEFORE we start working to generate quotes and plan options for you.
  We are curious about options and still shopping around We will be making a change within 60 days We want relief A.S.A.P and  want to explore all options & make necessary changes for dramatic improvement We are curious about Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAa) We want to install a group HSA plan as soon as possible. We'd like a traditional plan with low co-pays for ER office vists and Rx. Plan design is more important than cost. We realize co-pay plans are over-rated and over-priced and we'd like some better priced options of some 100% plans that provide Stop-loss protection, co-pay plans don't give us.
Choose One:   Full access to all care nationwide w/o restrictions;& worldwide while traveling that is affordable is a priority All we want is lower office vist co-pays. We'll risk not being covered at all outside a small network.
Please Provide the Following Required Info: Employer contribution %-: (Must be  at least 50% of  employee's cost not including dependents.)    Current  group Monthly Premium- :   Individual Rate/Month  Family Rate/Month  Other ie employee+children or employee+spouse  rates if applicable Anniversary Date:Exact name of current plan, carrier name  and type  (ie HMO, POS, PPO) -:      

   Before we provide our census info, we have a few questions. Please call us at your earliest convenience.
                       
                              Census Information - required to calculate rates
          Employee/Name (optional)                           Sex                   Age                 Spouse                              Children
                                                                                                     (M,F)                                                      (Age)                         (number of)