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Group Health Insurance Form
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Group Health Insurance Form
Complete this form to provide basic information for a group health insurance quote.
Please enter the company name.
Please enter the company name.
What is your first name?
What is your first name?
What is your last name?
What is your last name?
What is your email address?
What is your email address?
What is your phone number?
What is your phone number?
What is your title?
What is your title?
Please enter the company's primary location address.
Please enter the company's primary location address.
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
How many years has the company been in business?
How many years has the company been in business?
What is the nature of the business?
What is the nature of the business? (Please provide a brief description.)
Please select the types of coverage you are interested in:
Please select the types of coverage you are interested in:
Select All
Health
Dental
Vision
Does the company currently have a group health insurance plan?
Does the company currently have a group health insurance plan?
Yes
No
What is the name of the insurance company that the existing health insurance plan is underwritten through?
What is the name of the insurance company that the existing health insurance plan is underwritten through?
How many employees will be enrolled in this plan?
How many employees will be enrolled in this plan?
Additional Comments
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
How did you hear about us?
How did you hear about us?
Current customer
Referred by...
Google search
Agency's website
Email newsletter
Facebook
Instagram
Twitter
Other
Please share who referred you to us.
Please share who referred you to us.
Can you share what you typed into Google?
Can you share what you typed into Google?
Please let us know how you heard about us.
Please let us know how you heard about us.
Consent
*
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree
Michele Bolling
516-535-3550
http://www.hiramcohen.com
mbolling@hiramcohen.com
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