This is a request for a quote, submitting this form does not obligate you to purchase any products nor does it guarantee coverage. Do Not Cancel existing coverage until you have been contacted by our insurance professionals. Please complete this form as accurately as possible. Insurance rates are subject to change. If you prefer, you may print this form and fax it to 601-982-9429.
 


Name
Title
Company Name
Address
 
Email
Phone
Fax
   
General Information
 
Does your firm currently have group health insurance? Yes No  
If yes, what company?
Total Employees
Employees participating
Number of Employees employed outside Mississippi
Percentage Employer contributes toward Employee Cost
Renewal Date
  *All Small group plans require 50% employer contribution.
Current Coverage

Coverage type HMO
  Major Medical 90/10
  Major Medical 80/20
  Major Medical 70/30
  Major Medical 50/50

  Check the correct deductible amount below
  250 500 1000 Other; if other, what amount ?
  Do you have a physician co-payment ? Yes No
Dental Coverage? Yes No
 
Employee Census
Gender and Age or Date of Birth of the employee are mandatory. The Spouse's age or DOB should be included if requesting Employee/Spouse or Family coverage. Number of children should be included if selecting Employee/Child(ren) or Family coverage. If you only have employee data, simply submit that.
 
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Employee
Spouse
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(M/F)
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Additional Information
(Are there special considerations that should be included in the rating of this group? This is a web secure form for confidentiality.)