TrustPoint Insurance - Group Health

Who we represent:

GROUP HEALTH INSURANCE QUOTE REQUEST
Personal Information
What is your name?	*Last
	*First
	*Middle
What is the name of your company?	Company's Name
What is your address?	Street
	City
	State
	Zip
What is your position?	Position
What is your e-mail address?	*e-mail
What is your telephone number?	Telephone
What is your fax number?	Fax
What is the best time to call?	Time to Call
Does your company currently have an insurance carrier?	Carrier	Yes No
If you have a carrier, what is it?	Name of Current Carrier
If you have a carrier, what is the anniversary date of your current plan?	Anniversary Date
What is the total number of employees in your company?	Total Number of Employees
How many employees are you looking to insure?	Number of Employees to be Insured
Are premiums paid by your company for employee only or family, too?	Employee Only	Employee and Family
My current rate for____ coverage is:	Single Husband & Wife Single Parent & Child Full Family
Are there insurance carriers you would like quoted?	If yes, please list the company names
What type of plan do you want compared?	HMO Plan Dual Option Plan (PPO/POS)	HMO Plan Dual Option Plan
If you want an HMO or Dual Option Plan compared, choose from the following co-payments:	Co-payments
If you want an HMO or Dual Option Plan compared, do you want a prescription plan?	Prescription Plan	Yes No
If you want Dual Option Plan compared, please choose from the following deductible:	Deductible
If you want Dual Option Plan compared, please choose from the following co-insurances:	Co-insurances
What do you like or dislike about your current plan?	Likes or Dislikes
Additional remarks or requests	Remarks or Requests
For a quote click on the submit button below
Please be advised that coverage cannot be bound, altered or amended by leaving a message at this web site. Please contact the local Trustpoint office that handles your account and our associates will be happy to assist you.

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