Health Insurance

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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?
Last
First
Middle
What is the name of your company?
Company's Name
What is your address?
Street
City
State
Zip
What is your position?
Position
What is your e-mail address?
e-mail
What is your telephone number?
Telephone
What is your fax number?
Fax
What is the best time to call?
Time to Call
Does your company currently have an insurance carrier?
Carrier
Yes No
If you have a carrier, what is it?
Name of Current
Carrier
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
Employees
How many employees are you looking to insure?
Number of
Employees
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:
Single
Husband & Wife
Single Parent &
Child
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?
HMO Plan
Dual Option Plan
(PPO/POS)
HMO Plan
Dual Option Plan
If you want an HMO or Dual Option Plan compared, choose from the following co-payments:
Co-payments
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:
Deductible
If you want Dual Option Plan compared, please choose from the following co-insurances:
Co-insurances
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
Census
Company Name
State
City
Zip
Employee Data
Employee No.
Birth Date (mm/dd/yy)
Gender
Select Coverage
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
Employee 6
Employee 7
Employee 8
Employee 9
Employee 10
Employee 11
Employee 12
Employee 13
Employee 14
Employee 15
Employee 16
Employee 17
Employee 18
Employee 19
Employee 20
Employee 21
Employee 22
Employee 23
Employee 24
Employee 25
Employee 26
Employee 27
Employee 28
Employee 29
Employee 30
Employee 31
Employee 32
Employee 33
Employee 34
Employee 35
Employee 36
Employee 37
Employee 38
Employee 39
Employee 40
Employee 41
Employee 42
Employee 43
Employee 44
Employee 45
Employee 46
Employee 47
Employee 48
Employee 49
Employee 50
     
 
The Wayne Oakland Agency

PO Box 3158 | Oak Brook, IL 60522-3158
Phone 248-649-6006
Fax 630-402-6390
 
 
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