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	This is a strictly confidential web-quoting service. This information is not sold and you are not put on a mailing list. The confidential information you provide us is for our consultants to more accurately quote and rate plan recommendations to you based on your feedback on our census form. = Required Fields About You      First Name  Last Name  Your Title/Position  Your E-mail Address:     Business Information      Company Name:  City State Select a State Alabama Alaska Arizona California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey North Carolina North Dakota Ohio Oklahoma Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia West Virginia Wisconsin Wyoming   Zip code  County (not country)  Phone Number ( )  Best time to contact Select AM PM Evenings Nature of Business:     (e.g. - machine shop, lawyers..)  Number of Employees   (full time only - 30+ hours)     Current Insurance Situation     Does your company currently offer group health insurance? Select...... Yes No If you do not currently offer coverage, you do not need to answer the next 4 questions. You can use the CTRL key to make multiple selections. Name of Current Insurance Carrier: Types of insurance currently offered: PPO HMO Indemnity Hospital/Surgical Only Reasons for Dissatisfaction withexisting plan: Bad Plan Design Price Increases Customer Service Expenses Not Covered PPO/ HMO Network Other Month of Renewal of Existing.Coverage: Not Sure Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.     Plan Preferences (use the CTRL for multiple selections)    Types of coverage you would like quotes on: PPO HMO Indemnity Hospital Only Additional Insurance Options Wanted: Dental Disability Vision Fertility   Additional Comments   Please provide any additional specific information about your group that will help us recommend a medical plan to meet your needs and/or budget.Include any brief information about preexisting conditions that you are concerned about obtaining coverage for.      Submit your Request for Quotation        Thank You! Within the next 1-3 business days we will either ask for additional information or e-mail price and summary information to the address provided.  You are welcome  to provide additional information about your needs by completing the brief survey below. (EE=EMPLOYEE, ES=EMPLOYEE+SPOUSE, EC-EMPL+CHIILD(REN), FAM=FAMILY) Census Form: (Optional)             Gender Age  Coverage Gender Age Coverage             Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None Male Female <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ EE ES EC Fam None

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