Coe-Brooke Insurance Agency, Inc.  ▪  2805 Bridge Avenue  ▪  Point Pleasant, New Jersey 08742

Group Health Insurance Quote

General Information

Legal Name of Business:
Contact Name:
Address:
City:    State:    Zip:
Business Phone:    Fax:
Best Time To Call:    AM   PM
Contact Email Address:


Type of Business

Type of Business:
Standard Industry Code (if known):
# of Full Time Employees:          # of Part Time Employees:
Give a complete description of any
type of hazardous/dangerous duties
performed by your employees:

 

Current Group Health Insurance Information

Carrier (Company) Name (not agency):
Please give a brief description of your current Group Health plan:


Benefits Desired

Major Medical Deductible:     Optional Pregnancy Coverage: yes  no
Dental Coverage: yes  no Supplemental Accident Coverage: yes  no
Disability Insurance: yes  no PCS Card:
(Prescription Discount Option)
yes  no
Group Life Insurance:

 
Amount:

yes  no


$

PPO Option: yes  no
HMO Option: yes  no


Employee Information

Please list all employees you wish to cover:
Employee Name
Date of Birth
Age
Sex
Dependent Status
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
If you were not able to list all employees you wish to cover in the spaces above,
please use the Additional Comments section below
or indicate that you will fax or email an additional listing.


Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


Disclaimer

I understand that my coverage (or changes in coverage) ARE NOT binding via this on-line request; Changes ARE considered binding when I receive an email (or fax) response from my agent indicating that they have received my request.

 I have read and agree with the disclaimer.

(Box must be checked before request can be sent)

Copyright 2006-2015.    Coe-Brooke Insurance Agency, Inc.    Ph. 732-899-6800    Fax 732-899-0026