Group Health Insurance Quote Request

Please complete the following information and Census Form if you would like to obtain a group health insurance quote. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

If you have more than 50 employees, just submit the form twice. You only need to enter the company name and your email address on the second form, along with the employee information.

Personal Information

What is your name?




What is the name of your company?

What is your address?





What is your position?


What is your e-mail address?


What is your telephone number?


What is your fax number?


What is the best time to call?

Time to Call

Does your company currently have an insurance carrier?


Yes No

If you have a carrier, what is it?

Name of Current

If you have a carrier, what is the anniversary date of your current plan?

Anniversary Date

What is the total number of employees in your company?

Total Number of

How many employees are you looking to insure?

Number of
to be Insured

Are premiums paid by your company for employee only or family, too?

Employee Only

Employee and Family

My current rate for____coverage is:


Husband & Wife

Single Parent &

Full Family

Are there insurance carriers you would like quoted?

If yes, please list the company names

What type of plan do you want compared?


If you want an HMO or Dual Option Plan compared, do you want a prescription plan?

Prescription Plan

Yes No

If you want Dual Option Plan compared, please choose from the following deductible:


What do you like or dislike about your current plan?

Likes or Dislikes

Additional remarks or requests

Remarks or Requests


For a quote click on the submit button below

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Insurance products offered through LPL Financial or its licensed affiliates.

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