Group Profile Form

Employer Group Health Insurance Profile

* Indicates required field

Company Name *

Industry *

Years in Business *

Primary Contact *

First

Last

Title *

Business Address *

Line 1

Line 2

City

State

Zip Code

Country

SIC Code *

How much of the premium will you contribute towards employee portion?
Select One *

How much premium will you pay towards dependent portion? (can be any amount from 0-100%) *

When would you like coverage to start? *

How long after date of hire until employees become eligible for benefits?
Select One *

Currently offer group medical insurance? *

Yes No

Current renewal date? *

Name of Current Medical insurer? *

Phone Number *

Fax Number *

Email *

Number of hours employees must work per week to be eligible for benefits?
Select One *

Total number of Owners and Employees on payroll? *

Average number of employees working at least 17.5 hours per week over the last 12 months? *

Number of employees currently eligible for benefits? (Based on those working at least 17.5 hours per week) *

Currently offer group dental insurance? *

Yes No

Current renewal date? *

Name of current dental insurer? *

Comments *

Submit