Posts Tagged ‘health insurance quote’

Group Health Insurance Quote

Friday, May 21st, 2010

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

Individual Health Insurance Quote

Friday, May 21st, 2010

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
Street Address
City and Zip
County
Phone Number
Alternate Telephone
Email Address
Applicant / Family Member to be enrolled
Is this applicant currently insured with major medical or has been within the last 30 days
Applicant Gender
Applicant height (example 5'8")
Applicant Weight (lbs.)
Applicant Birth Date
Applicant Tobacco Use
Spouse Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Spouse Height (example 5'8")
Spouse Weight (lbs.)
Spouse Birth Date
Spouse Tobacco Use
Child 1 Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Child 1 Height
Child 1 Weight
Child 1 Birth Date
Child 2 Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Child 2 Height
Child 2 Weight
Child 2 Birth Date
Child 3 Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Child 3 Height
Child 3 Weight
Child 3 Birth Date
Child 4 Gender
Is this applicant currently insured with major medical or has been within the last 30 days
Child 4 Height
Child 4 Weight
Child 4 Birth Date
Explain any health problem that could affect premium:
Any special requests or remarks?
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other: