Group Health Quote Form - The Zutz Group

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Group Health Insurance

Contact Information
Your Name:
Company:
Address:
City:
State:	Zip:
Business Phone:	Fax Number:
E-mail Address:

Type of Business
Type of Business:
Standard Industry Code (if known):
No. of Full Time Employees:	No. of Part Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Health Insurance Information
Carrier (Company) Name (not agency):
Please give a brief description of your current Group Health plan:

Benefits Desired
Major Medical Deductible:		Optional Pregnancy Coverage:	Yes No
Dental Coverage:	Yes No	Supplemental Accident Coverage:	Yes No
Disability Insurance:	Yes No	PCS Card: (Prescription Discount Option)	Yes No
Group Life Insurance: Amount:	Yes No $	PPO Option:	Yes No
Group Life Insurance: Amount:	Yes No $	HMO Option:	Yes No

Employee Information
Please list all employees you wish to cover:
Employee Name	Date of Birth	Age	Sex	Dependent Status
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or e-mail an additional listing.

Additional Comments

Please click the "Submit Quote" button to send your quote request.

This is a request for quotation only. No coverage is in effect until bound by an insurance carrier.

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