Group Health Quote

Please complete and submit the following form. This information will be useful in helping us generate a quote and prepare to consult with you on your Group Health Insurance needs.

If you prefer to speak with a representative during normal business hours, call us Monday through Friday, 9:00am – 5:00pm EST at 610-494-8270

Employer Name:

Contact Name:

Title:

Address:

Phone:

Fax:

Contact\'s E-mail:

  

Business Type:

  

Preferred Plan Type:

Preferred Medical CoPay:

 other: 

Preferred Prescription CoPay:

 other: 

Preferred Carrier:

Additional Comments:



Describe the group members:
*If you have more than 20 members in your group please fax the information to us at 610-497-5583.

Employee# Birthday Gender Contract Type Home Zip Code
1  
2  
3  
4  
5  
6  
7  
8  
9  
10  
11  
12  
13  
14  
15  
16  
17  
18  
19  
20