Company Name:	____________________________		Phone:	____________________________
Address:	____________________________		Fax:	____________________________
City, State, Zip:	____________________________		Contact:	____________________________
Type of Business or Industry:	____________________________		Email:	____________________________
Current Health Company:	____________________________		Renewal Date:	____________________________
Current Premium:	____________________________		SIC Code:	____________________________
Current Plan Design (circle):	Deductible: 0 500 1,000 1,500 2,500 5,000		Co-Insurance:	100% 90% 80%
Current Employee Benefits (circle):	Dental/Eye Care 401K Disability Group Life Cafe/Section 125
Also interested In (circle):	Dental/Eye Care 401K Disability Group Life Cafe/Section 125

	Employee Name	Gender (M/F)	Age	Spouse Age	# of Children	Home Zip Code	Type*
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9
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15

 

 

*Type: ee- employee only es – employee & spouse ec – employee & children fam – family

** Do any employees listed work at a different location or different state? Yes No If Yes, note proper Zip Code

Medical Questions :

1. Are any employees or dependents currently pregnant? Yes No
2. Has anyone been confined to a hospital in the past 24 months? Yes No
3. Are any employees currently disabled? Yes No
4. Are any employees on COBRA or State Continuation? Yes No
5. Has anyone received treatment for cancer, stroke, diabetes, psychological/alcohol/drug
   treatments and/or disorder of the heart/kidney/immune system? Yes No
   If “Yes” give details: ___________________________________________________________________________

Please complete and fax to 636-349-0402