Large Group: 49+ Employees
Health Care Rate Quote Request


	We represent a large selection of health care plans available. Featuring a full line of Health Care Plans including Major Medical Plans, HMO Plans, and Dental Insurance from Companies such as: Blue Cross & Blue Shield of MN, Health Partners, MEDICA, Preferred One.


	1) Employer Contact Representative:


		Name:

	Company Name:

		Address:

		E-mail:

		Phone:

		Fax:


	2) Information about your company:


		Total number of Employees:

	Number of Employees working more than 20 hours/week:


	Employees working more than 20 hours waiving coverage:


	Less than 49 Employees in the previous calendar year?

		Number of Employees participating:

	Number of Employees employed in Minnesota:


	Percentage Employer contributes toward Employee Cost:


	Current Health Care Carrier:

		Renewal Date:


	3) Coverage Selection:


		*Coverage type?*

	*Dental* *Coverage ?*


	4) Specific Carrier:


		To make multiple selections hold down the "ctrl" key.



	5) Employee Census:

Employee name is optional, the following is mandatory:

Sex of Employee
Employee Date of Birth - mm/dd/yy format please
Spouse's Date of Birth must be included if requesting coverage - mm/dd/yy format please
Children's ages must be included if requesting coverage and should be separated by commas

Employee

Employee

Employee

Spouse

Children�s

Name

Sex

Date of Birth

Date of Birth

Ages

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22