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Group Health Profile


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Information
Today's Date
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/ /
Requested Effective Date
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/ /
Company Name
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First Name
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Last Name
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Type of Industry
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Total W-2 Employees
Required
Total Number of 1099 Employees
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Street
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City
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State
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ZIP / Postal Code
Required
Primary Phone Number
Required
Fax Number
Optional
E-Mail Address
Required
Current Benefit Plan
Current Group Health Company
Optional
Current Premium
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Health Plan
Optional
Deductible Amount
Optional
Co-insurance
Optional
Prescription Deductible
Optional
Prescription Co-pay
Optional
New Employee Waiting Peroid
Optional
Serious or Chronic illness or injury
Optional

Serious illness or injury description
Optional
Other Employee Benefits
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Ancillary Company
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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