Get a Group Quote

Group Information

Group Name (required*)

Contact Name (required*)

Contact Email (required*)

Phone Number

Requested Effective Date

Zip (required*)

Nature of Business (required*)

SIC Code

Current Carrier

Any 1099 Employees?

Quotes Specifications

Would you like age banded rates or Composite rates?

Please tell us the minimum amount of hours your employees can work to qualify for health insurance:

Employer contribution for employee & dependents (required* - Can be a percentage, minimum of 50% of the lowest priced plan your company offers or a dollar amount equal to that affect):

EE Dep

Please check all products to be included in your quote.

All Products Listed BelowInclude AD&D/LTD/STD

Anthem Blue Cross Blue Shield

MedicalDentalAncillary

Cigna self-funded (20 or more lives )

MedicalDentalAncillary

Delta Dental

MedicalDentalAncillary

MetLife

MedicalDentalAncillary

Rocky Mountain Health Plans

MedicalDentalAncillary

UnitedHealthcare

MedicalDentalAncillary

Vision Service Plan (VSP)

Vision Insurance

Census

Please provide the following information for each employee:

• Relationship (Employee, Spouse/Partner or Child/Dependent)

• First Name, Last Name

• Age, Date of Birth

• Gender

• Tobacco Use (Required for Medical Only)

• Zip Code

Please list all Spouse/Partner and Child/Dependent information directly below the Employee's with whom they are associated.

As part of a sale of a health insurance product, I am required by law to advise you that should you purchase health insurance from me or another licensed Agent from our Insurance Agency, the Agency usually will receive compensation in the form of a commission. This is paid by the carrier and does not affect your costs whatsoever