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Group Health Insurance

Health Insurance is one of the most desirable benefits to employees and often the most expensive benefits for employers to provide. The rising cost of group health insurance has made it increasingly more difficult for employers to continue providing plans.

Here are some common health plan concepts you need to know:

Copayments, Deductibles, & Coinsurance: Copay refers to the fixed fee paid by the insured for specific services. Copays do not apply toward deductibles or the out-of-pocket maximum. A deductible refers to the amount of covered expenses you pay each calendar year before benefits are paid under the policy. After the deductible is met, you and the insurance company begin sharing expenses. Plans offer different percentages of coinsurance.

Group Health Plans: Creating a group health plan will require gathering employee census data for your group of employees in order to receive quotes. Quotes generated prior to health carriers doing a thorough investigation of medical histories and are, therefore, subject to change once applications are completed and mailed. Employer's still have the right to reject the insurance if the costs change due to underwriting. Group plans often have a modest life policy attached.

Group Health Participation and Sponsorship: Group health plans are subject to certain participation levels of all eligible employees. Additionally, each state mandates that employers contribute a minimum percentage towards each employee’s group health premium.

Health insurance is very complex and varies greatly from plan to plan. We always look at multiple plans and compare features prior to advising you or recommending a plan. Furthermore, we advocate slightly higher copays and deductibles in order to discourage over utilization by employees.

*Please Provide as much information as possible to assure the most accurate quotes. Leave blank if you are not sure of an answer.

*See our Privacy policy for confidentiality.

General Information

This section only needs to be completed once for multiple lines of coverage

Name of Business:

Name of Owners/Officers:

Contact Name:

Contact Phone & Fax:

Phone: Fax:

Contact E-mail Address:

Address:

City:

State: Zip:

Business Info:

C-Corporation
S-Corporation
LLC

Sole-Proprietor

Partnership

LLP/Other

Years in Business:

Fed. Tax ID or Social Security Number:

Business Description:

Current/Previous Insurance Information

Current insurance company:

Describe Your Current Health Plan:

Policy Period:

Effective Date: Expiration Date:

Benefits Information

Deductible:

Quote PPO:

No Yes

Doctor's Copay:

Quote HMO:

No Yes

Drug Copay:

Quote POS

No Yes

Quote Group Life Coverage

No Yes

Quote Dental Coverage:

No Yes

Life Amount:

Quote Disability Coverage:

No Yes

Census Data Information

*Important Note*

If you have more than 10 employees, please open this Health Census Form (Adobe pdf) and

save it to your computer to type directly on it, or print it out to complete it by hand.

If you have 10 or less, complete your information below:

Employee Name	Sex	Dependent Status	DOB/AGE	Spouse DOB/Age	#of Children	Employee's
Employee Name	Sex	Dependent Status	DOB/AGE	Spouse DOB/Age	#of Children	State	Zipcode
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F

Additional Comments & Information

Please tell us anything else you think might be helpful to know in order to provide accurate insurance quotes:

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