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Group Health Insurance QUOTE

Centerpoint Insurance Group can help you develop benefit programs that make sense for your organization and your employees. Benefit programs that offer Group Health, Dental, Life, etc. are necessary to attract and retain good employees.

GROUP HEALTH INSURANCE QUOTE REQUEST FORM

General Information
Legal Name of Business:
Contact Name:
Address:
City:
State:    Zip: 
Business Phone:
Fax:
Best Time To Call:   AM   PM
Contact Email Address:

Type of Business
Type of Business:
Standard Industry Code (if known):
# of Full Time Employees:
# of Part Time Employees:
Give a complete description of any
type of hazardous/dangerous duties
performed by your employees:

Current Group Health Insurance Information
Carrier (Company) Name (not agency):
Please give a brief description of your current Group Health plan:

Benefits Desired
Major Medical Deductible: Optional Pregnancy Coverage: yes
no
Dental Coverage: yes
no		 Supplemental Accident Coverage: yes
no
Disability Insurance: yes
no		 PCS Card:
(Prescription Discount Option) 		yes
no
Group Life Insurance:

 
Amount:

 yes
no

$

 PPO Option: yes
no
HMO Option: yes
no

Employee Information
Please list all employees you wish to cover:
Employee Name Date of Birth Age Sex Dependent Status
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
If you were not able to list all employees you wish to cover in the spaces above,please use the Additional Comments section below or indicate that you will fax or email an additional listing.

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   
 
3900 E. Mexico Avenue, Suite 850 • Denver, CO 80210 • 888-933-0375 • 303-333-1391 Fax • Info@cptins.com