Small Group Health Request Confirmation


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Small Group Health Information Request

We feature a full line of Health Care Plans including Major Medical Plans, HMO Plans, Dental Insurance & Short & Long Term Disability Income from Companies such as Blue Cross & Blue Shield of MN, Health Partners, MEDICA, Fortis.

This is a request for a quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Insurance rates are subject to change.

Name
Company Name
Address
City
State
Zip

E-mail
Phone
Fax

General Information

Total number of Employees
Number of Employees working more than 20 hours/week
Employees working more than 20 hours waiving coverage
More than 49 Employees in the previous calendar year?	Yes No
Number of Employees participating
Number of Employees employed in Minnesota
*Percentage Employer contributes toward Employee Cost
Current Health Care Carrier
Renewal Date

**Most Small group plans require 50% employer contribution.*

Preferences

Coverage type?	Major Medical 80/20 with deductible
	250 500 1000 deductible
	Co-payment (High Coverage Option)
Dental Coverage?	Yes No

Companies Plans Requesting Information On

MEDICA
HealthPartners
BlueCross BlueShield of MN

Employee Census

(The Employee Name is optional, Sex and Employee Date of Birth (DOB) are mandatory, Spouse's DOB must be included if requesting coverage, Children's ages must be included if requesting coverage and should be separated by commas.

Employee Name	Employee DOB	Spouse DOB	Dependent Children Ages
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Employee Name	Employee DOB	Spouse DOB	Dependent Children Ages
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Please comment on any employees over 65 and not on Medicare.

Additional Comments