Quick Quote Request For Groups

Company Name

 # Employees
# Covered Employees
Address
 City
State
 Zip
Contact Name
Title
Phone
Fax
Type of Business
 SIC (if known)
 Years in Business
Current Health Insurance Carrier
 Name of Association (if applicable)
Current Medical Rates:
Employee Only

 Employee +Child
 Employee + Children
 Employee + Spouse
 Family
Current Product Type
(POS, PPO, HMO)
 Office Visit Copay
($5, $10, $15)
 Rx Copay
 Coinsurance Level
(100/80, 90/70, etc.)
Describe Employer Contribution Toward Employee Benefits (i.e. – employer pays 80% of premium, employer pays only single rate, etc.)

Name of Workers Compensation Carrier

Date of Next Rate Renewal
 Name of Current Broker (If applicable)
Number of Full-Time Employees Waiving Coverage
 Reason For Waiving Coverage
Are you aware of any significant health problems or ongoing medical conditions among any employees or family members (i.e. – diabetes, heart disease, cancer, chronic back problems, pregnancies, pending transplants, pending surgery, etc.)? If yes, please describe briefly.

Census (Please complete the following information)

Eligible Employee
Name (optional)
Date of
Birth
Sex
Zip Code
of Residence
Employee
Only
Parent/
Child
Parent/
Children
Employee
+ Spouse
Family
1.
Male
Female
2.
Male
Female
3.
Male
Female
4.
Male
Female
5.
Male
Female
6.
Male
Female
7.
Male
Female
8.
Male
Female
9.
Male
Female
10.
Male
Female
11.
Male
Female
12.
Male
Female
13.
Male
Female
14.
Male
Female
15.
Male
Female
16.
Male
Female
17.
Male
Female
18.
Male
Female
19.
Male
Female
20.
Male
Female
21.
Male
Female
22.
Male
Female
23.
Male
Female
24.
Male
Female
25.
Male
Female
26.
Male
Female
27.
Male
Female
28.
Male
Female
29.
Male
Female
30.
Male
Female
31.
Male
Female
32.
Male
Female
33.
Male
Female
34.
Male
Female
35.
Male
Female
36.
Male
Female
37.
Male
Female
38.
Male
Female
39.
Male
Female
40.
Male
Female
41.
Male
Female
42.
Male
Female
43.
Male
Female
44.
Male
Female
45.
Male
Female
46.
Male
Female
47.
Male
Female
48.
Male
Female
49.
Male
Female
50.
Male
Female
By submitting this census via email, I authorize Benefits Network, Inc. to seek rate quotes on our behalf.
Name
Title