Clark & Morrison Insurance Agency, Inc.

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Group Health Insurance

For the fastest and most accurate business insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only. Please note that no coverages can be bound through this form.

Thank You!

Business Information

Business Name:
Address:
City:	State: ZIP:
Contact Name:
Phone:	fax:
Email:

Group Health Census Information

Name (optional)	Gender	Date of Birth (or accurate age)	Family Status* (See Below)
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S
	M F		F, H, P or S

* 'F' = Family, 'H' = Husband/Wife, 'P' = Parent & Child(ren), 'S' = Single

Group Health Coverages

High deductible
catastrophic plan: Y N

Do you prefer a:

PPO Option : Y N

POS Option : Y N

HMO Option : Y N

Drug Card : Y N

Dental: Y N

Vision: Y N

Thank you for your time in submitting this Group Health Insurance Quote form. One of our representatives will respond to your submission as soon as possible! Please take note that no coverage is bound by this quote form. All quotes are estimates based on the information provided.