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Group Health Insurance
Quote Request

This Group Health Plan Quote Request page is designed to provide minimal information necessary for insurers to make preliminary risk assessments and to develop an initial proposal that meets the needs of your organization and your employees or members.

To request a proposal, go to the form below and complete the online questionnaire. Then, click on the “Submit” button to tell us what you want. No cost. No obligation.

Our program is unique. While the health plan is the centerpiece, it is only a part of our multi-component system. Our plan can help employers and groups build a workplace Fitness Culture program while promoting employee capabilities and productivity.

For employees or group members, our advocacy and assistance programs will help you better manage your personal and family healthcare affairs in less time and at lower cost.

If you have questions or need additional information, go to our Contact Us Page.

To request your proposal Start here . . . . .

Group / Employer Online Quote Request

Please note that all fields followed by an asterisk must be filled in.

Name of Group or Employer*
Name of Group or Employer*

Street Address*
Street Address*

City and State*
City and State*

Zip / Postal Code*
Zip / Postal Code*

First Name*
First Name*

Last Name*
Last Name*

Business Phone*
Business Phone*

E-mail Address*
E-mail Address*

Number of Locations*
Number of Locations*

S I C Code and Business Operation Description*
S I C Code and Business Operation Description*

Prior Group Health Insurance Plan*
Prior Group Health Insurance Plan*

	Yes
	No

If Prior Group Health Plan, Name of Insurer*
If Prior Group Health Plan, Name of Insurer*

Date To Start Requested Coverage*
Date To Start Requested Coverage*

Type Health Plan Desired*
Type Health Plan Desired*

	Traditional Indemnity Fee For Service Plan;
	Preferred Provider Organization (PPO) Plan;
	Point of Service (POS) Plan;
	Health Maintenance Organization (HMO) Plan;
	Health Savings Account (HSA) Plan;
	Health Reimbursement Arrangement (HRA) Plan

Health Plan Individual Deductible Amount Desired*
Health Plan Individual Deductible Amount Desired*

	$500;
	$1,000;
	$1,500;
	$2,000;
	$2,500;
	$5,000;
	Other (See Comments)

Desired Health Plan Coinsurance Factor*
Desired Health Plan Coinsurance Factor*

	50%;
	60%;
	70%;
	80%;
	90%;
	100%

Employee Life Insurance Coverage Desired

	Yes - Flat Amount (See Comments);
	Yes - Annual Salary Multiple (See Comments);
	No

Dependent Life Insurance Coverage Desired

	Yes - (See Comments);
	No

Dental Insurance Coverage Desired

	Yes - Basic Insurance Plan;
	Yes - Better Insurance Plan;
	Yes - Discount Value Plan;
	No Dental Plan.

Vision Plan Desired

	Yes;
	No.

Insurance-Related and Wellness Plans Desired

	Patient Care / Healthcare Advocacy Plan;
	Medical Self Care Prevention Plan;
	Medical Self Care Management Plan;
	Personal Fitness / Workplace Wellness Plan;
	No Thanks.

Other Insurance Plans Desired

	Short Term Disability;
	Long Term Disability;
	Accidental Injury Supplement;
	Long Term Care Insurance;
	Accidental Death or Dismemberment (ADD);
	Other (See Comments);
	No Other Plans.

Total Number of Eligible Employees*
Total Number of Eligible Employees*

Percentage of Employee Premium Paid By Employer*
Percentage of Employee Premium Paid By Employer*

Number of Employees Participating*
Number of Employees Participating*

Dependents - Number of Employee + Spouse Participants

Dependents - Number of Employee + Children Participants

Dependents - Number of Employee + Family Participants

Percentage of Dependent Premium Paid By Employer

Total Number of Dependents Participating*
Total Number of Dependents Participating*

Total Number of Lives Participating (Employees + Dependents)*
Total Number of Lives Participating (Employees + Dependents)*

Summary Census: Please provide a list of each participating employee identified by initials or number (for example, Emp#1) and giving the following summary information for each employee and for each dependent participant (for example, E1 + S + Ch 1 + Ch2). - gender, date of birth, height and weight.*
Summary Census: Please provide a list of each participating employee identified by initials or number (for example, Emp#1) and giving the following summary information for each employee and for each dependent participant (for example, E1 + S + Ch 1 + Ch2). - gender, date of birth, height and weight.*

Comments or Questions: Include any requests for additional coverage or specific plan design features or any questions you have regarding coverage or process.

How To Know What You Don't Know: Would you like to receive an email copy of the latest Wiser Health Insurance Consumer Guide, at no cost, no obligation?

	Yes;
	No Thanks.

Acknowledgement, Signature and Date: This quote request form is intended to provide information to generate a preliminary group proposal from one or more insurers. Such preliminary quotes will be subject to and conditioned on securing individual group member enrollment applications, group / business profile forms and applications and other documents as may be necessary for proper risk assessment and underwriting. You should not terminate any current health insurance coverage which would be replaced by the requested coverage prior to receiving written approval of and issuance of replacement insurance from an approved licensed insurer. Please acknowledge your understanding of this condition and confirm the validity of the information offered above in this form by your electronic signature and the date signed in the space below:*
Acknowledgement, Signature and Date: This quote request form is intended to provide information to generate a preliminary group proposal from one or more insurers. Such preliminary quotes will be subject to and conditioned on securing individual group member enrollment applications, group / business profile forms and applications and other documents as may be necessary for proper risk assessment and underwriting. You should not terminate any current health insurance coverage which would be replaced by the requested coverage prior to receiving written approval of and issuance of replacement insurance from an approved licensed insurer. Please acknowledge your understanding of this condition and confirm the validity of the information offered above in this form by your electronic signature and the date signed in the space below:*

Please enter the word that you see below.

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Group Health InsuranceQuote Request

Group Health Insurance
Quote Request