For an Employee Benefits Quote, please
complete this form:

5185 Peachtree Parkway
Suite 300, The Forum
Norcross, GA 30092
Ph: (678) 715-9513 | Fax: (770) 447-0704

Type of Quote:    Select... Medical Dental

Employer's Name:

Email:    

Business Address:

City:      

State:    

Zip code:

Employer's nature of business:


Phone

Who is the current carrier?

Current medical plan type: [ HMO]   [ POS] [ PPO]  

Current medical coinsurance level: [ 100/70]   [ 90/70] [ Other ]

What are the current rates? Employee Employee & Spouse
    Employee & Child Family Employee & Child

Is prospect experiencing any specific problems with the current plan? Select... Yes No
If yes, please describe:


Are there other coverages in force such as dental or disability? Select... Yes No

What is the employer's contribution for: [Employee %]  [Dependent %]

Are there any significant ongoing medical conditions within the group including pregnancies? Select... Yes No
If yes, please describe:


How many employees are eligible for coverage?

How many employees are covered in current plan?

Deos prospect have an agent currently servicing their account? Select... Yes No

Census

Please provide census info including age, sex, and dependent status for each employee to be covered. For more employees, please fax a list to (770)447-0704.

EE Employee; ES Employee & Spouse; EC Employee & Child(ren); FA Family

Employee 01  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 02  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 03  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 04  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 05  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 06  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 07  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 08  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 09  [Age ] [SexMaleFemale]  [Status EE ES EC FA] Employee 10  [Age ] [SexMaleFemale]  [Status EE ES EC FA]