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.
* required information

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

 mm/dd/yyyy

Employer Pays

% of Employee Premium

Employer Pays

% of Dependents Premium

Intended Effective Date

 mm/dd/yyyy

Will a Sec125 Plan Be Available?

Questions or Comments


Please complete for each employee

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages

Employee Name

Gender

Date of Birth

Zip Code

Select Type of Coverage

Spouse Age

#Children

Ages
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