myhealthinsuranceplace.com

Obtaining a group quote is as easy as 1-2-3. Just fill out the form below; or if you prefer, contact us and we will be happy guide you through the process.

Section 1: Company information

Company Name::

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

Contact person:

Type of business:

Section 2: Coverage Information

Current Insurance Carrier:

Current deductible:

Note: If your current plan's specifications are not listed here, or if you have multiple plans, please use the Notes section below.

Current co-insurance:

Current max. out-of-pocket cost:

Please check the types of plans
that interest you: (hold down the
shift key to check more than 1
item)

Please check the coverages you
would like to see: (hold down the
shift key to check more than 1
item)

Notes:

Section 3: Employee Census


Gender:	Age/DOB:	Status:	# of Children (if known):

Add additional employees or
comments here:

Any medical conditions you are
aware of(no names please):

HMO
PPO
Traditional
Health Savings Acct.
Partly Self-funded

Medical
Dental
Vision
Group Life
Short-term disability