Group Health Insurance Quote for Employers

Group Insurance Quote

Company Name (legal name)

Contact Name

Contact Phone Number

Email Address

Business Address (Zip Code minimum)

Industry Type

Current Health Plan in Place? YesNo

If yes: Carrier Name & Renewal Month

Are You Offering Dental, Vision, or Other Voluntary Benefits? DentalVisionLifeOther

Preferred Contact Method TextEmailPhone

Number of Full-Time Employees

Number of Part-Time Employees

Attach Employee Census (optional)

If no census, list number of employees, birthdates & zip codes