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Group Health Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!

Your Personal/Group Data:

Your Name:

Your Business Name:

Street Address:

City:

State: (Must be Minnesota)

Zip Code:

E-Mail (REQUIRED):

E-Mail again for accuracy:

Phone:

Fax (optional):

(If more than 5 in group, contact us at: 952-469-0425 )

Please Check the Group Products your company wants
to make available to your employees:
Group Health Group Dental Group Vision
Group Life Employee Benefits

Group Underwriting Information:

Employee #1 Name	M/F	Age	Status

Occupation	Status	Currently Insured?	Plan type

Employee #2 Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type

Employee #3 Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type

Employee #4 Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type

Employee #5 Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type

Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

Employee Health Problems?
(Do any of your employees have special health problems or insurance needs? If no, write "none".)

Group Plan Needs?
(Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for!)

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