Errors & Omissions Insurance Application

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Group Health Census

Please fill out the following application to obtain pricing for a group health policy.

COMPANY INFORMATION
Company Name*
Business Operations*

Please provide a precise description of what your company does.
Address*
Street AddressCityState / Province / RegionZIP / Postal Code
Phone*
Fax
Email*
Enter EmailConfirm Email
Do you currently have a health plan?
- Yes
- No
What is your current health plan?*
What type is your current health plan?*
- HMO
- HSA
- PPO
- POS
- EPO
- Dual Option
Please check all that apply.
What is the premium for your current health plan?*
Do you have more than one location?*
- Yes
- No
Address*
Street AddressCityState / Province / RegionZIP / Postal Code
Any employees paid by commission (and/or) paid as independent contractors? (FORM 1099)*
- Yes
- No
Any COBRA participants previously employed by you?*
- Yes
- No
What types of employees would you like to be quoted?*
- All
- Salary
- Management
- Non-Union
- Hourly
Number of full-time employees*

Full-Time is 30 hours per week or more.
EMPLOYER PAYMENT OPTIONS
Percentage of costs to be paid for employees*
Percentage of costs to be paid for dependents*
What date do you want this to be effective?*
PROPOSAL OPTIONS
Which products are you looking for?*
- All
- Medical
- Dental
- Life
- Vision
Please check all that apply.
Which plan designs are you interested in?*
- All
- HMO
- HSA
- PPO
- POS
- OTHER
Please check all that apply.

COMPANY CENSUS

Please provide the following information for each of your employees. If you have more than 10, please upload the information in a spreadsheet format using the option below.
Employee #1
Name*
Date of Birth
Plan Type
- Medical HMO or PPO
- Dental HMO or PPO
Sex
Spouse?
Number of children
Cobra
Home Zip Code
Life Only*
Life Amount

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