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Group Health Insurance Quote

Please fill out the information below and to get a quote from us. Thank you!

General Information

Business Name

Contact Person
Primary Address of Business
City State Zip
Other Locations
E-Mail
Phone Number
Fax Number:

Please fill out census form below:

1. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

2. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

3. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

4. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

5. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

6. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

7. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:
8. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

9. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

10. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

11. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

12. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

13. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

14. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

15. Name: Sex: M F
Age as of effective date:
Spouse age:
Children number:

 

Changes to census in next year:

Additions to census in past year:

Current carrier:
Annual anniversary date:
Percentage of last increase:

Health issues within group:

General description of known claim activity:

Any other comments:

 


Sheffield Group Health Plans
Atlanta/Buckhead
Norcross/Marietta
(404) 351-4775
Fax:  (404) 351-4771
(770) 980-0046