Group Health Benefits
Completing the following information will help us start the process of shopping the market to making sure you have the right coverage at the most competitive price available.
Company Name *
Your answer
Name of Owner/Contact *
Your answer
Contact Phone *
Your answer
Contact Email *
Your answer
Street
Your answer
City & State
Your answer
Zip
Your answer
Description of Operations *
Your answer
Group Health Benefits Currently in Place? *
If Yes, Current Health Carrier
Your answer
Number of Eligible Employees
If Possible, Tell Us a Bit More About What You Are Looking For *
(shopping for group benefits for a new company, looking for more affordable benefits, looking to explore benefit options regarding supplemental/ancillary benefits such as dental/vision/AFLAC style supplemental benefits, etc.)
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.