You may get a premium quotation on line for all your Personal and Business insurance needs, such as: Auto, Homeowners, Renters, Condo Units, Individual Health, Group Health, Short Term Health, International Health, and Life Insurance - Businessowners Insurance, General Liability Insurance Workers Compensation Insurance for Offices, Retail and Wholesale Stores, Service Businesses, Manufacturers, Contractors and much more.

All Personal and Commercial Insurance Programs can be custom tailored to fit your individual and business specific needs.

Group Health Insurance Quote Request

For a quick and competitive quote on your Group Health Insurance, please complete the following information. To effectively market this coverage for you, we need as much information as possible.
Licensed in the states of Illinois, Wisconsin and Nevada
MUST HAVE AT LEAST TWO EMPLOYEES TO QUALIFY

Employer Information
Name of Business:*
Contact First Name: *
Contact Last Name: *
Address: *
City: *		State:* Zip Code:*
Phone: *		Fax:
Email:		County:*
Other Information your insurance agent should know:
Number of Owners: *		Number of Full Time Employees:*
What industry is your company in? *
If you could not find your industry above, please describe here *

Insurance Information
Do you have group Insurance In Force?		Yes No
If "Yes", when does your current policy expire?		mm/dd/yy
If "Yes", what is the name of the insurance company? (Not agency)
Plan Deductible: *
Plan Co-Pay:
Proposed policy effective date: *		mm/dd/yyyy
Optional coverage: (check the ones you want)		Prescription Card Supplemental Accident Maternity Short/Long Term Disability Insurance Life Insurance
Please describe any other coverage you wish to be quoted on:

Remarks Section
Please use this space for any additional information, or to list additional employees:
How do you wish to be contacted:

Group Census
Please list all full-time employees below. (Fill out all applicable fields)
Empl. #	Employee Name *	Employee Gender		Employee Date of Birth	Spouse Date of Birth	Number of Children	Life Insurance?		Medical Insurance?
1.		M	F				Yes	No	Yes	No
2.		M	F				Yes	No	Yes	No
3.		M	F				Yes	No	Yes	No
4.		M	F				Yes	No	Yes	No
5.		M	F				Yes	No	Yes	No
6.		M	F				Yes	No	Yes	No
7.		M	F				Yes	No	Yes	No
8.		M	F				Yes	No	Yes	No
9.		M	F				Yes	No	Yes	No
10.		M	F				Yes	No	Yes	No
11.		M	F				Yes	No	Yes	No
12.		M	F				Yes	No	Yes	No
13		M	F				Yes	No	Yes	No
14.		M	F				Yes	No	Yes	No
15.		M	F				Yes	No	Yes	No