Request a Group Insurance Quote

We will be glad to provide a competitive quote

Due to the complexity of group quoting, contact Bev Haselman in the Leipsic office at 1 (877) 225-8436 for more information if you have more than 7 employees, or would like a PRESCREENED quote. If you have less than 7 employees and just would like to see a standard quote, feel free to fill out the following info and submit. Allow 5-10 business days for quote.

Quotes based off medical information given and are subject to change based on medical underwriting.

Fields marked with * are required. Please read our privacy policy.

Agent Information Which agent would you like to work with

Group Information * Group Name

* Street Address

* City

* State
* Zip Code

* Nature of Business

* Phone

Cell Phone

Fax

* Email

Deductibles and Copays Deductible
$
Out of Pocket
$
Office Visit Copay
$
Rx Copay
$
Generic/Name Brand Preferred Copay
$
Name Brand Non Preferred Copay
$

Employee Information Employee 1 Name

Gender
Employee 1 DOB

Employee 1 Age

Type of Coverage Employee 1 Spouse Age

Employee 1 Number of Children

Employee 2 Name

Gender
Employee 2 DOB

Employee 2 Age

Type of Coverage Employee 2 Spouse Age

Employee 2 Number of Children

Employee 3 Name

Gender
Employee 3 DOB

Employee 3 Age

Type of Coverage Employee 3 Spouse Age

Employee 3 Number of Children

Employee 4 Name

Gender
Employee 4 DOB

Employee 4 Age

Type of Coverage Employee 4 Spouse Age

Employee 4 Number of Children

Employee 5 Name

Gender
Employee 5 DOB

Employee 5 Age

Type of Coverage
Employee 5 Spouse Age

Employee 5 Number of Children

Employee 6 Name

Gender
Employee 6 DOB

Employee 6 Age

Type of Coverage Employee 6 Spouse Age

Employee 6 Number of Children

Employee 7 Name

Gender
Employee 7 DOB

Employee 7 Age

Type of Coverage Employee 7 Spouse Age

Employee 7 Number of Children

Your Quote Effective date requested?
[ dd/mm/yyyy ]
How would you like us to reply back to you?

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