Dallas Health Insurance

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Group Health Insurance Quotes

Name of Business:

Type of Corp (S, C, LLC)

Type of Business / SIC Code:

Contact Name:

Number of Employees:

Email:

Plan Design:

Day Time Phone:

Desired Annual Deductible:

Address:

Coverage Types:
(check all that apply)

Health
Short Term Disability
Long Term Disability
Dental
Life

City:

State:

Zip :

Please List ALL Employees (Full Time = 30 hours or more and Part-time < 30 hours a week)

Type of Coverage*:
EO = Employee Only : ES= Employee and Spouse : EC= Employee/Child(ren) : EF= Employee and Family

If a full time employee is currently coverage through Group coverage with a Spouse, please indicate with a check mark.

Employee Name	Indicate FT or PT	DOB	Gender	Home Zip Code	Type Of Coverage*	Check if covered through Spouse's Group Plan

Please list any general comments, questions, or concerns here.