Contact customer@iscolorado.com Wednesday, September 8, 2010

Get Group Quote

GENERAL INFORMATION
* Name:
      
* Address:
      
* City:
* State:
 * Zip:

  
* Day Phone:
 Night Phone:
    
Best Time To Call:
AM
PM		    
* E-mail 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:
Yes   No 		PPO Option:
Yes   No
Amount:
$ 		HMO Option:
Yes   No
       
EMPLOYEE INFORMATION
Please list all employees you wish to cover:
Employee Name: DOB: Age: Sex: Dependent Status:
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
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.