PERSONAL INFORMATION
Company Name:
First Name:
Last Name:
Your Address:
City:
County:
State:
Zip Code:
Work Number:
Alternative Number:
Best Time to Call:	Please Select Morning Afternoon Evening
Your E-mail Address:
GENERAL INFORMATION
Type of Company:	Please Select Corporation-C Company-LLC S-Corporation Partnership Sole Proprietor
Do you have Business Group Health?	Please Select Yes No
If yes, when does it expire?
If yes, current insurance carrier:
Type of Business:
Number of Locations:
Number of Employees in Current Plan:
HEALTH PLAN INFORMATION
Type of Health Plan	Please Select HMO PPO/POS Medical Savings Account Not Sure
Current Deductible or Hospital Fee:	Please Select $2000 $1500 $1000 $750 $500 $250
Office Visit Co-Pay?	Yes No
If yes, Co-Pay Amount:
Prescription Drug (RX) Co-Pay?	Yes No
If yes, Co-Pay Amount:
Do you have a Dental Plan in place?	Yes No
If no, do you want Dental?	Yes No
Do you have a Vision Plan in place?	Yes No
If no, do you want Vision?	Yes No
Section 125/Cafeteria/Premium Only Plan?	Yes No
Voluntary Benefits (employee paid) Plan?	Yes No
If yes, Current Carrier(s):
Employer Contribution % for Employees:	Please Select None 10% 25% 30% 40% 50% 60% 70% 80% 90% 100%
Contribution % for Employee Dependants:	Please Select None 10% 25% 30% 40% 50% 60% 70% 80% 90% 100%
Fully or Partially Self-Funded Plans?	Yes No
Additional Group Comments, Questions?