Group Health Insurance Quote

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

Name
Company Name
Street Address
City and Zip
What is your position?
Email Address
Phone Number
Alternate Telephone
Fax Number
Best time to call?
Does your company currently have health insurance
If so, name of current carrier
Anniversary Date of current plan
Total Number of Employees (including officers/owners)
Number of Employees to be Insured
Are premiums paid by your company for employee only or spouse too?
Current rate for coverage is:
Please list the company you would not like quoted:
What type of plan do you want compared?
Please choose from the following deductibles:
Would you like a Prescription Plan?
Please select from the following co-insurances:
What do you like or dislike about your current plan?
Additional remarks or requests
Census
Company Name
City
Zip Code
Employee Data
Employee 1
Birth Date
Gender
Zip Code
Select Coverage
Employee 2
Birth Date
Gender
Zip Code
Select Coverage
Employee 3
Birth Date
Gender
Zip Code
Select Coverage
Employee 5
Birth Date
Gender
Zip Code
Select Coverage
Employee 6
Birth Date
Gender
Zip Code
Select Coverage
Employee 7
Birth Date
Gender
Zip Code
Select Coverage
Employee 8
Birth Date
Gender
Zip Code
Select Coverage
Employee 9
Birth Date
Gender
Zip Code
Select Coverage
Employee 10
Birth Date
Gender
Zip Code
Select Coverage
If more employees are to be covered, please send census data by email to info@HatcherKimrey.com

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