Allen Insurance Agency  

Call: 1-800-335-0639

 

Hello,

Thank you for the opportunity to quote your companies group health insurance premiums and earn your business.

Group Health Insurance Quote Request

Complete the following Census Form  if you would like to obtain a group health insurance quote for your business.
This is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
If you have more than fifty employees, just let us know and we will send you another form. Call us at 800-335-0639 if you have any questions.
Bold fields are required:
Your: First Name :  
Last Name:  
Name of your company:  
Company Address:  
City:  
Zip  
What is your position:  
Email:  
Telephone:  
 Best Time to Call:
Fax:
Does your company currently have group insurance?
If yes name of carrier:
Current monthly premium (total):
Anniversary date of your current plan?
Total number of employees in your company:
Number of employees to be insured:
What type of plan do you want quoted:
Why are you shopping:

Employee data

Employee No.

Birth Date

Gender

Select Coverage

Employee 1  

 

 

 

Employee 2

Employee 3

Employee 4

Employee 5

Employee 6

Employee 7

Employee 8

Employee 9

Employee 10

Employee 11

Employee 12

Employee 13

Employee 14

Employee 15

Employee 16

Employee 17

Employee 18

Employee 19

Employee 20

Employee 21

Employee 22

Employee 23

Employee 24

Employee 25

Employee 26

Employee 27

Employee 28

Employee 29

Employee 30

Employee 31

Employee 32

Employee 33

Employee 34

Employee 35

Employee 36

Employee 37

Employee 38

Employee 39

Employee 40

Employee 41

Employee 42

Employee 43

Employee 44

Employee 45

Employee 46

Employee 47

Employee 48

Employee 49

Employee 50

Allen Insurance Agency is not employed by, connected with or endorsed by the State Department of Insurance, United States Government or the Federal Medicare program

Back -  Privacy - Site Map - Contact - Companies - About Us - Search - Life Quote - Health Quote - Dental Quote  Logon
Copyright ©2010 Allen Insurance Agency