Group Health Insurance
  
First Name:
Last Name:
Company:
Physical Address:
City:
State:
Zip:
County:
Phone:
Fax:
Email:
Nature of business, services rendered:
Does your business have current group coverage? Yes
No
If yes, who is the carrier?
Please fax your most current medical plan invoice to: 800.852.6810
Please fax your medical plan benefits information to: 800.852.6810
To the best of your knowledge, regarding any employee or dependent:
Any claims over $5,000 in the past 12 months? Yes
No
Any hospitalizations in the past 12 months? Yes
No
Any prescribed medications in the past 12 months? Yes
No
Currently pregnant? Yes
No


Employees census of full-time
(We need gender, age and coverage type needed)

Sex
Age
Coverage Type