We represent a large selection of plans available for the small employer. Including health, dental, disability, and 401K plans. The carriers we represent include Blue Cross & Blue Shield of MN, Health Partners, MEDICA, Preferred One.
Please note: This is not an application for group health insurance. Completing this form gives us information to determine what medical plans best meet your groups’ needs.
Employer Contact Representative:
Name:
Company Name:
Address:
E-mail:
Phone:
Fax:
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:
Is your company interested in:
Coverage type?
Dental Coverage ?
If you would like information on a specific carrier, hit the company you desire more information on. Use the “ctrl” key for multiple selections. Don’t forget to click the “submit” button after the selection.
Employee Census
Please note: Employee name is optional, but the following must be completed:
Employee
Spouse
Children’s
Name
Sex
Date of Birth
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