Information About Your Business

Type of Quote

Business Name

  Life Health Dental  Vision Long Term Care Disability

Number Years
in Business

Contact Name

Address

City

County

State

Two Letter State Abbreviation

Zip

Telephone

Please include area code

Fax

Email Address

Nature of
Business

If you are requesting a health insurance quote it would be helpful
if you provided the following information.

Present
Carrier

Plan Design

Current Rates

$ Single $ Double $ Family

Renewal Rates

$ Single $ Double $ Family

Renewal
Effective Date

mm/dd/yy

Health Issues within the group

Employer
Contribution

$

Total Number
of Employees

Full Time Part Time Cobra

Do you currently offer the coverage you are requesting a quote for? Yes No

Please complete the following for all eligible employees.  If you have more than 12 employees, please call our office at 608-873-8232.

Last Name

Gender

Tobacco User?

Date of Birth

Choose One

Employee 1

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage
 

Employee 2

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 3

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 4

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 5

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 6

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 7

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 8

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 9

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 10

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 11

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage

Employee 12

  Female
  Male

  No
  Yes

mm/dd/yy

  Employee Only
  Employee & Spouse
  Employee & Child
  Family
  Waive Coverage