R.L Evans Company, Inc.

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 Group Insurance - Quote Request / Census Form

To receive a FREE, no obligation quote for Group Health Insurance coverage, please complete the Group Health Risk Questionnaire and the online questionnaire below. For groups over 20, or for groups requesting life and/or disability coverage, please print and complete the Proposal Request Form and fax it to us at 206.448.3589.

Need Help? 206.448.7878 or 1.800.987.8199

Please complete as accurately as possible. Final rates are based upon actual enrollment of plan inception.

Company Name:

Contact's Name:*

E-Mail Address:*

Type of Business:

Physical Address:

City:

State:

Zip/Postal Code:

Phone:

Fax:

What type of insurance are you looking for?
Medical       Dental  Other: 

Current Medical Carrier:

Indicate none if none.

Plan Name or Design:

Current Dental Carrier:

Indicate none if none.

Plan Name or Design:

Renewal Date:

Employer Pays:

% of Employee Premium

Employer Pays:

% of Dependents Premium

Intended Effective Date:

Will a Sec125 Plan Be Available?

 

Questions or Comments

Please complete for each employee

 

Name (first name is fine)

Gender

Employee Date of Birth

Residence
Zip Code 

Type of Coverage

Spouse Age or DOB

# of
Children

Children's Ages

1

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

2

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

3

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

4

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

5

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

6

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

7

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

8

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

9

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

10

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

11

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

12

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

13

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

14

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

15

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

16

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

17

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

18

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

19

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

20

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

 Ages

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Plaza 600 Building : 600 Stewart Street : Suite 1210 : Seattle, WA 98101
Telephone 206.448.7878 : Facsimile 206.448.3589
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