Group Health Insurance Quotation

Please complete and submit the following form. This information will be useful in helping us generate a quote and prepare to consult with you on your Group Health Insurance needs.

If you prefer to speak with a representative during normal business hours, call us Monday through Friday, 9:00am – 5:00pm EST at 610-494-8270.

Employer Name:
Contact Name:
Title:
Address:
Phone:
Fax:
Contact’s E-mail:
Business Type:
Preferred Plan Type:
Preferred Medical CoPay:
other:
Preferred Prescription CoPay:

other:
Preferred Carrier:
Additional Comments:

Describe the group members:
*If you have more than 20 members in your group please fax the information to us at 610-497-5583.

Employee # Birthday Gender Contract Type Home Zip Code
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