Avanti Benefits Corporation -- Group Health Quote Form

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GROUP HEALTH INSURANCE QUOTE		We would like to provide you with a free, no-obligation group health insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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.