Group Health Insurance Form

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 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?
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

Patrick Battle, CIC, CPRIA

Agency Partner

38 years of experience, education and expertise as a risk advisor/manager to some of the most successful families in the world.

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Group Health Insurance Form

Group Health Insurance Form

Additional Comments

Patrick Battle, CIC, CPRIA

RiskRevu^TM Newsletter

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Group Health Insurance Form

Group Health Insurance Form

Additional Comments

Patrick Battle, CIC, CPRIA

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RiskRevu^TM Newsletter