MASS MARKETING INSURANCE CONSULTANTS

This process enables you to request a group health insurance quote. Please print and complete and submit the health plan options, business information, and group census.

Click here if you have more than 10 employees

Health Plan Options

Choice Of Plans:


	Preferred Provider Organization (PPO)
	Health Maintenance Organization (HMO)
	Health Savings Account (HSA)

Deductibles:

$250

$500

$1000

$1500

$2500

$5000

Doctors Office Visit Copay:

Yes

Prescription Drug Card:

Yes

Co-Insurance Options:

100%/80%

90%/70%

80%/60%

Optional Benefits:

	Maternity (Paid as any other sickness)
	Dental Insurance
	Life/AD&D
	Disability Insurance

Business Information

Business Name:
Email:
Street:
City / State:	,
Zip Code:
Business Phone:
Fax:
Contact Person:
Association Name:	(if applicable)
Member I.D.	(I.D.not required to obtain a quote)
SIC Code or Description of Business:
Requested Effective Date:

Total Number of Employees:
(Please complete the following employee information)

Group Census

	Employee Name	Date of Birth mm/dd/yyyy	Gender M or F	State Employee Resides In	Coverage Employee (EE) Employee/Sp (ES) Employee/Ch (EC) Family (EF)
1
2
3
4
5
6
7
8
9
10

This process does not constitute an offer of insurance and the quote provided is for illustrative and informational purposes only. Actual rates are subject to changes in demographics and overall health status of your group.

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