Group Health Insurance - Insured 4 Life by Leland T. Proshek at Chart Advisors, Inc.- Health, Group, Life & Disiability Insurance & Advising

GROUP HEALTH INSURANCE QUOTE FORM

Complete the form below now or print a blank form to fax later by clicking here.
Use your TAB key to move quickly between fields.

Company Name:	Contact Name:
Street Address:	Area code: ( ) Phone:
City: State: Zip:	Area code: ( ) Fax:


Employee Name	Gender	Age	Spouses Age	# of Children	Health Issues & Medications
#1:	Male Female

#2:	Male Female

#3:	Male Female

#4:	Male Female

#5:	Male Female

#6:	Male Female

#7:	Male Female

#8:	Male Female

#9:	Male Female

#10:	Male Female

Current Health Insurance Company:
Deductable: $
Co-insurance: 100% 80/20% 70/30% 50/50%
Maximum Co-insurance: $2,500 $5,000 $10,000 Other
Monthly Premium: $
Do you have employees living in other states? Yes No
What is more important: reduce premium increase benefits

Your E-mail Address:

Other Employees Not Listed Above:

Additional information: