Group Insurance Quote Request

Getting Started

• Privacy Statement

There are a few things we will need from you in order to get started. Most of it is self-explanatory,
but if you need help give us a call at (702) 892-0266.

Contact Information

Name:
Title / Position:
E-mail Address:
Referred By:

Business Information

Legal Business Name:
DBA:
Years / Mo In Business:
Corporate Address:
City:
State:
Zip Code:
Phone:
Fax:
List zip codes of all locations:
List zip codes of all out of area/state employees:
Nature of your business:
List Chamber of Commerce Affiliations:
# of full-time employees:
# of part-time employees:
Can you provide the most recent Quarter's State Wage and Tax Report?
1099 labor/workers represents	% of our workforce
Approx number of employees who will be enrolling in the plan
Percentage of insurance premium the employer will pay toward employees health plan(s)
Percentage toward employees Ancillary products
Percentage toward employees Dependents

Your Current Group Health Insurance Situation

Do you have existing group health coverage?
Name of current group health insurance company
Month of Renewal for Current Coverage
Number of employees currently enrolled in group plan
Name of existing broker

Please indicate the group insurance products you are interested in

Health	Life	Cancer	Pension Plans
Vision	Long-term disability	AD&D	Long Term Care
Dental	Short-term disability	HDHP w/HSA	Other
401K	Voluntary Products	Section 125

Additional Comments

Please include short comments regarding any known on-going medical conditions or prescriptions among the employees and dependents to be covered by the health plan (if already known to you - do not include the person’s names).

Are there any other issues you want us to consider? If so, please summarize:

Employee Census Information

	Please provide us information for each employee (up to 15) to be covered. If you have more than 15 employees, call us (702) 892-0266, fax us (702) 892-0212, or e-mail us at Quote Request.
	Employee Name	Date of Birth	Sex	Dependent Status	Spouse DOB	# Children
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

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