Group Insurance Form

Name of Business:

(Name will appear on all documents)

Type of Business :

(SIC) Code (Required for some carriers)

Contact Name:

Position:

Phone :

(Example:000-000-0000)

Fax:

( ) -

(Example:000-000-0000)

Email Address:

Address 1:

Address 2:

City:

State:

Zip Code:

# of Full Time Employees:

# of Employees on Group Plan:

# of Out Of State Employees:

Current Plan Information (Recommended for comparison reports)

Carrier Name:

Plan Name / Plan Type:

Monthly Premium:

($)

Plan Renewal Date:

January February March April May June July August September October November December

Comments: