Do you currently have a Group Health Insurance plan within your company or business?

Yes No

 

What is the name of your Company or Business?

 

Address

Principal Activity

Number of employees

List the current census of people employed at your firm below:

Employee Name	Date of Birth	Sex  M/F	Coverage for Spouse? Y/N	Enter # Children if covered	Smoker / non smoker S/N	Dental Coverage? Y/N

Copy of most recent benefit statement available?

What benefits are you seeking? Reduce premiums, increased services and benefits, dental, prescriptions etc?

What is it about your present plan that you would like to improve? Please give details.

If you have statements or quotes on your current health insurance plan and costs for individual and family, how would you like to provide us these documents?

We will fax you @1-800-878-4127 or 316-775-3919 We are mailing it separately We will provide it to you at a later time. Other:

Please enter any other comments, questions or requests in the space provided below:

Tell us how you prefer us to get in touch with you:

Name
E-mail
Tel
FAX

Please contact me as soon as possible regarding this matter.

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