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(Small) Business or Groups Form

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Please fill out the form below and I will search the top-rated insurance companies to find you the best value for your insurance dollar.

Privacy: Information, including e-mail addresses, is never shared with any outside companies or individuals. The information we ask of our visitors is used by us to provide insurance rates to those who request quotes from us, and for no other purpose.


Please complete the following form and hit the "Submit" button.

Please check all types of plans you are considering:

Major Medical

Major Medical with Co- Pay Plan

Major Medical 100% Plan

Major Medical 80/20 Plan

Group Medical Savings Account Plan

 
First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Name of Company
Work Phone
FAX
E-mail

Please enter the number of employees to be covered by this health
insurance plan? (Be sure to answer with numbers only -- e.g., 4, not four.
Note: The number you enter here should not include any spouses or
dependents that will also be covered. under this plan.


Do you currently have an insurance carrier?


If yes, specify carrier and expiration date.


What type of health insurance do you currently offer?


What types of health insurance would you like? (check all that apply)

HMO
PPO
Point of Service (POS)
Self  Insure
Other
Traditional
Not sure

What types of coverage do you want? (check all that apply)

Medical
Prescription drug plan
Vision/eyewear
Mental health
Dental
Life
Wellness programs

When do you need your health plan to take effect?

-- mm/dd/yy

What percentage of the premium will your company cover?


What maximum deductible do you prefer?


How many years has your company been in business?


What is the five digit ZIP code of your office location?


Please describe in detail any additional requirements you may have.



John Krogh.
Copyright 2003 AARK John Krogh.  All rights reserved.
Revised: 11/15/06