Saperstein Agency, Inc.

GROUP
HEALTH
INSURANCE QUOTE		 We would like to provide you with a free, no-obligation group health insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. We will contact you when this is received to discuss your insurance needs more adequately.

General Information
Legal Name of Business:
Contact Name:     Position:
Address:
City:   State:   Zip:
Business Phone:   Fax:
Best Time To Call:   AM   PM
Business WebSite Address: http://
*Contact Email Address (Required):


Type of Business
Type of Business:
# of Full Time Employees:         # of Part Time Employees:
# of Employees Requesting Coverage:

 

Current Group Health Insurance Information

Insurance Company Name
(not agency):

Current Premium:

Renewal Date:

$

Please give a brief description of your current Group Health plan:


Benefits Desired

Major Medical Deductible:

    PCS Card:
(Prescription Discount Option) 		yes  no
Dental Coverage: yes  no In/Out Network Plan: yes  no
Disability Insurance: yes  no HMO Only: yes  no
Group Life Insurance:

 
Amount:

 yes  no

$

    


Employee Information

Please list the number of employee / family coverage's needed below:

# of Employee Only

# of Employee
plus Spouse

# of Employee
plus Child(ren)

# of Employee, Spouse
plus Child(ren)


Please Answer the Following Questions
to enable us to serve you better

Please indicate your concern regarding your current insurance protection:
Price
Too Much Coverage
Too Little Coverage		 Insurance Company/Agency not familiar
       with your business or household need

How would you rate the service that your current agent/broker provides:
Excellent Adequate Poor

If you could change one thing about your current insurance protection, what would it be:


Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

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