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Group Insurance
Contact Information
Contact Name:
Address:
City:
State:
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Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
About Your Business
Sole Proprietor
Partnership
Corporation
LLC
Association
Do you currently have Group Health insurance?
Yes
No
If "Yes", when does your current policy expire?
If "Yes", who are you currently insured with?
Type of Business
Description of Business Operations:
Number of Locations
Number of Employees
1 - 5
6 - 10
11 - 20
21 - 50
51 - 75
76 - 99
100 and above
Plan Type
HMO
PPO / POS
Major Medical
Not Sure
.
Optional coverage (check the ones you may want)
Group Dental Insurance
Group Long Term Care
Group Disability Insurance
401 K & Retirement Plans
Group Life Insurance
.
Details
Any Comments / Questions?
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The G&D Group