Hollister Insurance || Stuart Florida Health Insurance - Group

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Group

The quote you have requested requires that you complete the following form as completely and as accurately as possible. Once we receive your information we will expedite your request. The information you submit will be kept confidential and will be used for quoting purposes only. Thank you for allowing us to earn your business.

GROUP HEALTH INSURANCE QUOTE REQUEST FORM

If you have an updated census, please email it to quoterequest@hollisterins.com.

If you have more than 20 employees, please contact our office. Less than 20 employees, please fill out the form below.

Group Name required

Type of Business required

Address required

City required

State required

Zip Code required

Group Phone Number required

Client Status required Existing Client New Client

How did you hear about us?

Preferred Contact Name required

Contact Phone Number required

Contact Email Address required

Total Number of Employees required

Number of Participating Employees required

Employer Contribution of Benefits: Employee % required

Employer Contribution of Benefits: Dependent % required

Quote Due Date (mm/dd/yyyy)

Information Pertaining to Existing Coverage

Current Carrier(s) / Plan(s) / Start Date required

List your current carriers, the plans you utilize, and the start date of each.

Renewal Date (mm/dd/yyyy) required

HMO / PPO / Hospital / Network Currently Used

HMO / PPO / Hospital / Network Preferred

Individual Deductable

Family Deductable

Co-Pay %

Drug Card Co-Pay

Office Visit Co-Pay

Losses Over $5K / Large Ongoing Losses

List any losses over $5K you have had in the past year and any large ongoing losses.

Employee #1

Number of Employee's

Employee Name required

Gender required Male Female

Date of Birth (mm/dd/yyyy) required

Zip Code required

Coverage Type required

Employee #2

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #3

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #4

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #5

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #6

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #7

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #8

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #9

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #10

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #11

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #12

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #13

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #14

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #15

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #16

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #17

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #18

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #19

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Employee #20

Employee Name

Gender Male Female

Date of Birth (mm/dd/yyyy)

Zip Code

Coverage Type

Verification required